MOE TEP 1 0 RIC   E  0  R  P  T  T  PJi 
.  Scliool   of  Eur  sing 


IMPOTENCE  AND   STERILITY 

with 

Aberrations  of  the  Sexual  Function 

and 

SEX-GLAND  IMPLANTATION 


By 


G.  FRANK  LYDSTON,  M.D.,  D.C.L. 

Formerly  Professor  of  the  Surgical  Diseases  of  the  Genito-Urinary  Organs  and 

Syphilology  in  the  Medical  Department  of  the  State  University  of  Illinois, 

Member  of  the  American  Urological  Association,  Fellow  of 

the  American  Medical  Association,  Member  of  the 

Society  of  Authors,  London,  England,  etc. 


THE  RIVERTON  PRESS 
CHICAGO 

1917 


Copyright  1917 
G.  Frank  Lydston,  M.D. 


-709 


TO 
THE  MEMBERS 

OF 

THE  AMERICAN  UROLOGICAL  ASSOCIATION 

AS  A  SLIGHT  EXPRESSION  OF  APPRECIATION    OF  THE 

EARNEST  AND  CONSCIENTIOUS  WORK  OF 

THE 

GREATEST    ASSOCIATION  OF  ITS  KIND    IN  THE  WORLD,  W'HICH 

HAS    ACHIEVED  GREAT  CREDIT  FOR  ITSELF  AND  HAS 

EMPHASIZED  THE  DIGNITY  AND  IMPORTANCE 

OF  GENITO-URINARY    SURGERY, 

THIS    VOLUME    IS    RESPECTFULLY    INSCRIBED 

BY 

THE  AUTHOR 


FOREWORD 

MY  belief  that  there  is  room  for  still 
another  monograph  on  diseases  and 
aberrations  of  the  sex  function  is  sufficient 
explanation  for  this  volume.  The  advisa- 
bility of  presenting  in  permanent  form  my 
hormone  theory  of  aberrations  of  sex 
development  and  function  and  my  re- 
searches and  observations  in  the  field  of  sex- 
gland  implantation,  will  be  sufficiently  ob- 
vious to  those  laborers  in  the  vineyard  of 
science  who  have  learned  to  their  cost  that 
the  medical  press  alone  cannot  be  relied 
upon  to  perpetuate,  protect  and  give  last- 
ing credit  for  original  work.  It  is  hoped 
that  the  legal  profession  may  find  in  the 
chapters  on  Sterility,  Sex  Aberrations  and 
Sterilization,  material  of  forensic  value. 


G.  Frank  Lydston 


25  E.  Washington  St. 
Chicago 


CHAPTER    I. 

Aberrant  and  Imperfect  Differentiation  of  Sex. 

Hermaphroditism. 

The  relation  of  physical  deformities  of  congenital  origin  in- 
volving the  sexual  organs  to  abnormalities  and  imperfections  of 
the  sexual  function  is  most  important.  The  subjects  of  physically 
aberrant  sexual  differentiation  are  more  numerous  than  is  gener- 
ally believed ;  fortunately,  however,  the  majority  of  cases  are 
either  slightly  marked  or  of  but  little  practical  importance  as  re- 
gards their  physiologic  and  social  status. 

Certain  marked  cases  of  physical  aberr^ilion  of  sexual  struc- 
ture always  have  been  of  vital  importance  to  medical  jurists.  Her- 
maphroditism, so-called,  has  received  considerable  attention  from 
authorities  on  medical  jurisprudence.  In  England,  where  the  law 
of  primogeniture  prevails,  the  male  is  relatively  so  important  a 
factor  in  the  body  social  that  the  legal  traditions  upon  the  sub- 
ject of  hermaphroditism  have  been  much  more  enduring  and  im- 
portant than  elsewhere. 

As  our  knowledge  of  physiology  and  morphology  has  ad- 
vanced, however,  the  so-called  hermaphrodite  not  only  has  decreased 
in  frequency  in  all  social  systems,  but  is  a  much  less  important  fac- 
tor in  jurisprudence.  The  most  important  features  of  such  cases 
at  the  present  time  are  the  questions  of  :  1.  Impotence  and  sterility 
in  both  sexes.  2.  Sexual  perversion  and  inversion,  or  other  psycho- 
pathies of  a  sexual  type. 

That  the  evils  resulting  from  aberrations  of  structure  of  tlic 
sexual  organs  produce  mechanic  and  functional  obstacles  to  pro- 
creation is  not  at  all  remarkable  and  is  sufficient!}-  well  under- 
stood. 

The  psychosexual  aspect  of  the  question  is  not,  however,  so 
fully  and  intelligently  comprehended  as   it   should  be.     The   term 

—  7  — 


KAIPOTENCE   AND    STERILITY 

hermaphroditism  has  been  apphed  in  a  loose  and  unscientific  fashion, 
the  physical  conformation  of  the  subjects  being  accepted  as  the 
chief  factor  in  diagnosis.  Hermaphroditism  literally  implies  a 
mingling  of  the  physical  and  functional  qualities  of  both  sexes.  The 
crucial  test  as  now  accepted  is  the  existence  of  a  more  or  less 
perfectly  formed  testicle  and  ovary  in  the  same  individual.  Even 
from  this  stand-point,  the  existence  of  true  hermaphroditism  is 
open  to  serious  question.  If  hermaphroditism  be  accepted  as  im- 
plying the  performance  of  the  male  or  female  function  at  will,  such 
a  condition  cannot  possibly  exist  in  view  of  the  fact  that  the  sexual 
function  does  not  begin  and  end  with  the  act  of  sexual  congress, 
])rocreation  being  necessary  to  its  complete  fulfillment.  The  so- 
called  hermaphrodite  is  sterile — fortunately  for  society — and,  so 
far  as  procreation  is  concerned,  cannot  functionate  as  either  male 
or  female.  The  author  is  of  opinion  that,  while  pseudoherma- 
phroditism is  by  no  means  rare,  true  hermaphroditism  does  not, 
and  from  biologic  reasoning,  cannot  exist. 

Although  in  most  cases  of  pseudohermaphroditism  it  is  pos- 
sible to  classify  the  subject  as  either  male  or  female  with  greater 
or  less  ease,  it  must,  nevertheless,  be  acknowledged  that  cases  oc- 
casionally occur  in  which  the  differential  diagnosis  demands  the 
highest  degree  of  diagnostic  skill.  A  case  coming  under  the  ob- 
servation successively  of  Guyon  and  Fournier  pointedly  illustrates 
this.  These  distinguished  gentlemen  rendered  lengthy  and  dia- 
metrically-opposed opinions  as  to  the  sex  of  the  subject. 

Cases  occasionally  occur  in  which  a  differential  diagnosis  is 
impossible  until  the  age  of  puberty,  when  certain  sexual  attributes 
- — menstruation,  the  growth  of  beard,  changing  voice,  etc.,  as  the 
case  may  be — decide  the  question  of  sex.  In  very  rare  instances 
the  sex  cannot  be  decided  during  life. 

In  some  of  the  cases  of  alleged  hermaphroditism  the  subject 
not  only  does  not  present  what  can  justly  be  termed  an  admixture 
of  male  and  female  organs,  but  is  ]:)ractically  a  neuter,  being  with- 
out desire  or  cajiacity  to  perform  the  functions  of  either  sex. 
When,  however,  the  subject  of  general  and  local  malformation  also 
is  the  subject  of  sexual  perversion,  observation  of  the  case  may  in- 
dicate an  apparent  commingling  of  the  functional  capacity.  A  case 
coming  under  the  author's  observation  aptly  illustrates  this.  The 
subject  was  a  mulatto  cook  to  whose  case  the  author's  attention  was 

—  8  — 


IlKRMArnRODlTlSM 


Aherrant    p-yciKj>c"xvial    (lifferciuialion    with    iiniierfect    physical    (hf- 
fcreiitiatif)]!.    vScxual  organs  of  normal  form.  Init  undeveloped. 


called  by  .some  of  the  lads  of  the  neighborh(XJ(l.  who  came  for  relief 
from  typic  gonorrhea,  which  they  claimed  they  had  contracted  from 
him.  Investigation  proved  the  truth  of  tlie  hoys'  story.  This  hy- 
pospadiac  male  had  contracted  the  disease  in  the  normal  manner 
from  a  female  and,  subsequently,  performing  the  passive  role  in 
the  sexual  act.  had  given  the  disease  to  the  lads. 


IMPOTENXE    AND    STlvRlLlTY 

A  case  illustrating  the  difficulties  of  diagnosis  in  so-called  her- 
maphroditism is  re])orted  by  Dr.  (}.  ]v.  Green  : 

Cask. — A  liousemaid.  aged  24,  had  symptoms  which  seemed  to  point  to 
retained  menses.  She  was  five  feet  seven  inches  in  height,  of  dark  complexion, 
and  anemic  in  appearance,  i^'or  several  years  she  had  been  in  domestic 
service,  and  was  well  known  to  the  doctor  personally.  On  examination,  the 
external  genitals  appeared  to  be  those  of  a  woman ;  in  keeping  with  this  was 
the  arrangement  of  the  pubic  hair,  while  there  was  in  addition  considerable 
mammary  devel()])ment.  There  was  an  oval  body,  freely  movable,  in  the  right 
labium  and  a  similar  one  in  the  left.  On  separating  the  labia  a  clitoris  was 
found,  rather  larger  than  usual,  llelow  this  was  a  small  opening",  wdiich 
apparently  led  to  a  narrow  and  contracted  vagina.  Subsequent  examination, 
however,  under  ether,  revealed  a  very  different  state  of  things.  The  "swell- 
ings" in  the  labia  proved  to  be  testes  ;  the  labia  w^ere  formed  by  a  splitting 
of  the  scrotum  into  two  halves.  At  the  I)ottom  of  the  "split"  the  "clitoris" 
was  clearly  the  ])enis.  with  its  glans  only  developed,  and  without  the  corpus 
spongiosimi.  Upon  its  tmder  surface  there  was  a  groove  which  led  backward 
to  a  urethral  orifice,  into  wdiich  a  silver  female  catheter  easily  passed  into 
the  bladder.  The  sex  of  this  "housemaid"  was  cvidenth',  therefore,  male,  and 
the  ([uestion  arose  what  was  to  be  done  tmder  the  circumstances.  The  patient 
was  anxious  to  continue  being  a  woman,  but  the  law  does  not  allow  a  man 
to  masquerade  in  woman's  c!oth('s.  Dr.  (ireen  determined  that  the  difficulty 
would  be  met  if  he  were  to  remove  the  testicles  from  the  "labia."  This  was 
accordingly  successftdK'  done,  and  now.  in  his  tmse.xed  condition,  the  man 
has  restmied  his  ordinary  occtipation  of   that  of  a  "housemaid." 

-Aberrant  sextial  differentiation  may  not  involve  any  physical 
defects  of  the  sexttal  organs ;  it  may  be  ptirely  ])svchic,  and  de- 
])endent  u])on  im])erfection  dilferentiation  of  sexttal  affinity.  'J'hat 
there  is  an  essential  defect  in  the  psvchosexital  centers  of  the  cere- 
bral cortex  is  probable;  l)tU,  if  such  defect  exists,  it  is  too  occult 
for  detection  by  an}-  known  method  of  research.  Cases  of  psychic- 
ally defective  sexttal  diflerentiation  ])resent  themselves  under  three 
forms:  1.  Cases  with  normal  develo])ment  of  physical  sexttal 
t}])e,  both  general  and  local.  These  constitttte  the  class  of  cases 
in  which  sexual  ])erversion  is  least  likely  to  be  stispected.  2.  Cases 
of  normal  general  ])hysi(|tie,  but  defective  or  aberrant  develo])ment 
of  the  genitals.  3.  Cases  in  the  male  in  which  the  genitals  are 
im])erfecll}-   develo])ed  and   the  general   ])h\-si(|tte   effeminate. 

The  same  classification  a])])lies  to  both  male  and  female.  The 
atuhor  has.  howe\-er,  observed  homosextialit\-  oftcner  among  neti- 
ro])athic    temales   ot    an    tiltrafeminine   t\-])e   than    in   those   of   mas- 

—  10  — 


Ili-.R.MAPIIRODITISM 

culine   anrilnuc'>.      It    is   admitted    that    this   probably    is   an   excep- 
tional experience. 

Sextial  affinitx'  has  been  held  to  be  a  form  of  hun.^'er  which, 
traced  to  its  sotn'ce.  is  mereh'  chemic — or  at  least,  bio-chemic — 
affinitv.  \i  this  be  true,  as  the  author  believes  it  to  be.  imperfect 
differentiation  of  sexualitx'  >honld  be  exi)ected  to  lead  to  rever- 
>ional    ]ieculiarities    manifested    1)}'    >extial    perversions    of    \-ariotis 


['-(.■lul'ilK-nnaiiiirnditi-iii  (;il)errain  L;x-iiit>  iscxual  (litYc-rentiatii  )n  I, 
-liMwinLi-  totes,  which  were  rctaiiK-d  within  ilie  jielvis.  Suhject 
wa-  a  male. 


fornir^.  This  ])oint  will  be  more  ftill\-  disctissed  in  the  next  chapter. 
The  ])oint  that  the  atithor  desiro  to  make  here  is  that  pederasts. 
tn-nin_^s, — a  term  a])])Iied  1)\-  Ca<])ar  to  individuals  haviui.;-  "the 
l)o('_\'  of  a  man  and  the  >otil  ot  a  woman."" — and  some  other  sextial 
])erverts  (  invert>  e>])eciall_\  )  are  closel}'  akin  to  h\-pos])a(liacs  and 
ei)ispadiacs — so-called  herma])hro(liies.  Psychic  herma])hroditism 
or  psettdoherma])hroditi<m  ma_\'  be  (jtiite  as  readih'  acce])te(l  as 
a  ])os<il)ilit_\-  a<  ma_\-  the  i)h\'-ical   t\-pe.     The   stibjects  of   im])erfect 

—  11     - 


T.MPOTlvXCE   AND    STERILITY 

or    aberranl    sexual    differentiation    may    be    specially    classified    as 
follows : — 

1.  Imperfect     differeii-    ^Pederasts,  urnings,  subjects  of  bestiality  and  in- 
tiation     of     sexual     type  verts;  ;.  c,  individuals  with  a  sexual  affinity 

(affinity)    without   phys- <^  for  their  own  sex — homosexuality.   The  latter 

ical  defect,  either  general    ]  is  called  in  the  female  gynandry,  and,  in  the 

or  local.  1^         male,  androgyny.    This  class  is  not  numerous. 


2.  Defective — /.  c,  im- 
])erfect  or  aberrant — dif- 
ferentiation of  structure. 


( (/ )  The  simi)lest  variety.  Genital  defects  par- 
taking of  more  or  less  of  the  attributes  of 
the  opposite  sex,  with  normal  sexual  appe- 
tite. 

(/')  Genital  defects  of  similarly  atypic  conforma- 
tion, associated  with  perverted  sexual  appe- 
tite. 

((■)  -Aberrations  of  general  ])liysiquc  only — ''.  c  a 
physi(|ue  a])])roxim;iting  tliat  of  the  opposite 
sex — associated  witli  perversion  of  sexual  ap- 
petite. Most  cases  of  homosexuality  belong 
to  this  class. 

((/)  .Aberrations  of  general  physiciue  with  asso- 
ciated genital  defects  anrl  perverted  sexual 
appetite. 


In  class  2 — (/,  />,  d — are  embraced  e|)is])adias  and  bv])osi)adias 
;md  rudimentary  develo])ment  or  c'lbsence  of  uterus,  ovary,  testicle, 
and  ])enis. 

Mucb  of  tlie  rtibbisb  that  has  l)een  ])0])tilarl_\-  acce])ted  on  the 
(|t:estion  of  herma])hro(litism  has  been  jjromtili^ated  b\'  men  about 
town  and  ])h_\sicians  who  are  ii^norant  of  se.xual  niorpholoi^x'.  (  )n 
several  occasions  the  atuhor  has  been  invited  by  physicians  to  inspect 
a  wonderftil  herma])hro(lite,  which,  on  examination.  ])r()ved  to  be  a 
male  of  by  no  means  extraordinai-ily-defective  tv])e.  These  cases 
on  in\-esti,<4ation  ])roved  to  be  alUiclics  of  disrei)Utable  houses  in  which 
the  alleged  femininit\-  of  the  stibjecl  was  beinu'  devoted  to  ])roht- 
able  mercantile  desii^ns.  In  one  case — which  -was  claimed  to  be  a 
male  i)er\ert  -the  sttbject  afterward  confessed  that  his  ])erversion 
was  for  rex'entie  onl\-,  his  sextial  a])])etitc  beini;"  o'ratilied  only  in 
the  normrd  manner.  This  was  borne  otU  1)\-  the  testimony  of  some 
ot  hi>  intimate  associates. 


llKkMAPHRODITIS-M 


(ki}-,  one  of  the  older  writers  on  medical  jurisprudence,  classi- 
fied cases  of  genital  malformation  as  follows: — 

1.  Male  individuals  with 
.-uch  unusual  formations  of 
the  generative  organs  as  in 
many  respects  to  resemble 
tlie  female. 

1.  F  c  male  individuals 
with  such  unusual  forma- 
tions of  the  same  organs  as 
to  resemble  the  male. 

,1,  W'liere  a  mixture  of 
the  sexual  organs  of  l)oth 
sexes  is  cxliibited  without 
either  being  entire. 

It  is  obvious  that  there 
are  certain  acijttired  con- 
ditions which  wotild  fall 
tinder  the  above  classifi- 
cation, yet  wottld  not  be 
trtte  cases  of  aberrant 
sexual  diflerentiation : 
('.  (j..  a  ])rola])sed  and  hy- 
j)ertro])hied  uterus  has 
l)een  mistaken  for  a  ru- 
dimentar}-  i)enis.  and  fe- 
males thus  affected  have 
been  known  to  copttlate 
w  i  t  li  other  females. 
An  h\i)ertr()])hicd  cli- 
toris ma\'  be  nn'staken 
for  a  rudimentary  ])enis 
and  ma\'  ])erform  the 
male  ])art  in  co])ttlation. 
The  im])ortance  of  cau- 
tion in  deciding  the  sex 
in  cases  of  genital  mal- 
formation is  a])tl_\'  illtis- 
t  rated  l)y  a  celebrated 
case    occtirring    in    Chi- 


Al)errant  genito-exual  differentiatinn  (  hypo- 
spadiac).  Alale  txpe,  ])sycliosexually ; 
general  ])hy-i(|ue  of  female  type. 


cago.      In    this   ca>e    socielx'    was    electrified 


the    discoverv    that 


IMPOTENCE   AND   STERILITY 

a  supposed  young  lady  who  had  been  visiting  about  and  sleeping 
with  bona  fide  young  lady  friends  was  a  boy.  The  first  intima- 
tion of  the  truth  was  the  development  of  a  pronounced  beard  with  a 
bass  vocal  accompaniment. 

The  assertion  that  certain  cases  of  sexual  perve-rsion  are  akin 
to  epispadias  and  hypospadias  and  the  result  of  imperfect  differ- 
entiation, may  seem  a  trifle  far-fetched,  but  the  author  nevertheless 
holds  the  o])inion  that,  even  when  the  differentiation  of  sex  is 
complete  from  a  gross  physical  standpoint  it  still  is  possible  that 
the  receptive  and  generative  centers  of  sexual  sensibility  may  fail 
to  become  perfectly  differentiated.  The  result,  under  such  cir- 
cumstances, might  be,  on  the  one  hand,  sexual  apathy,  and,  upon 
the  other,  an  approximation  to  the  male  or  female  type  according 
to  the  circumstances  of  the  case.  Such  a  failure  of  development 
and  im])erfect  differentiation  of  structure  necessarily  would  be  too 
occult  for  detection  from  physical  character  by  any  means  of 
investigation  at  our  command.  It  is,  however,  only  too  well 
recognized  l)y  its  results  and  is  often  responsible  for  disgusting 
cases  of  sexual  perversion  that  society  is  prone  to  attribute  to  moral 
de])ravity.  This  point,  and  the  relation  of  reversion  of  type  to 
sexual  ])erversion,  will  be  more  fully  discussed  in  the  next  chapter. 
That  failure  of  differentiation  and  development  is  equally  re- 
s])onsible  for  certain  cases  of  sexual  perversion  and  instances  of 
hvpos])adias  and  e])is])adias  is  the  ])rincipal  ])oint  to  be  remem- 
bered at  this  juncture. 

Cases  of  gross  ])hysical  aberration  of  genital  structure  are  not 
difficult  to  account  for,  so  far  as  the  uiodits  operandi  of  their  forma- 
tion is  concerned  ;  l)ut  their  cause  is  not  so  readily  explicable. 

There  evidently  is  an  exhaustion  of  formative  energy  before 
the  occurrence  of  com])lete  fusion  of  the  two  lateral  segments,  of 
which  tlie  embryo  is  ])ractically  com])ose(l.  Defective  genital  forma- 
tion bears  the  same  relation  to  th.is  exhaustion  of  formative  energy 
as  do  crania  bifida.  sp>ina  bifida,  etc.  It  is  ol)vious  that  the  degree 
of  deformit}-  (lei)en(ls  entirely  u])on  the  ])eriod  at  which  develo])- 
mental  ])rogrcssi()n  ceases.  vSo  far  as  a])])earances  go.  one  would 
naturally  conclude  that  dilTerentiation  does  not  cease  at  a  very 
early  ])eriod  in  the  life-history  of  the  fetus,  else  what  is  ordinarily 
acce])ted  as  true  hei-niaphroditism  would  not  only  occur  in  reality. 
hut   would  be   fre(|uent. 

-^  14     - 


iii".i-;maimir()I)ITIs.m 

Geoflrov  St.  Jliliarc,  one  of  the  older  writers,  niapjjed  out  a 
verv  elal)orate  ])lan  in  explanation  of  liernia])hro(litism  in  a  work 
cspecialK'  devoted  to  that  subject,  lie  divided  the  ,^-enerative  a])- 
])aratus  into  a  series  of  ])ortions  or  segments,  three  in  each  lateral 
division.  The  n])])er  set  coni])rise(l  the  testes  and  ovaries  :  the  middle 
the    wonil).    jjrostate.    and    seminal    vesicles:    the    lower    the    i)enis. 


I  '-cudDlie-niiaiilirodilisni  (  alicrraiU  .^cii it o sexual  dilTcTtnliulion  j , 
sli<)\\-iiit4-  \nl\a.  pscinliiN  asiina,  and  absence  of  uterus.  Sul)ject 
\\";i-  a  male. 


scrotum,  clitoris,  and  vulva.  Accordino"  to  him,  therefore,  there 
nu'ght  occur  any  number  of  varieties  of  herma])hroditism,  accord- 
ins2;  to  the  combination  of  faulty  structures.  'Phis  scheme  was  de- 
fective because  of  the  fact  that,  in  spite  of  all  appearances  to  the 
contrary,  differentiation  ])ractically  never  falls  (|uite  short  of  de- 
terminini^-  one  or  the  other  sex. 

The  simjdest  ])lan  for  the  explanation  of  i^enital  deformities 
and  anomalies  is  to  remember  that  the  fetus  ])ractica]ly  develops  in 
two  lateral  segments  and  that  any  failure  of  union  at  the  genital 
furrow  will  result  in  a  greater  or  less  degree  of  aberration  of  genital 

—  15  — 


I.M1'(JT1{XCI-:    AM)    STI{RTIJTY 

ccjufoniiation.  The  view  that  hyposj)adias  and  epispadias  are  tlie 
result  of  atresia  and  ru])ture  of  the  fetal  m-ethra  apparently  is  un- 
tenable in  view  of  the  generally-defective  ])hysique  found  in  most 
cases  of  the  kind. 

The  relation  of  aberrations  of  genital  formation  to  sterility 
and  im])Otence  is  vcr}'  important.  Jmpotenxe  does  not  exist  in  the 
female  unless  there  be  atresia  or  complete  absence  of  the  vagina. 
Almost  any  aberration  of  the  structure  of  the  ovary,  tubes  or  uterus 
may,  however,  produce  sterility.  In  the  male  impotence  is  more 
likely  to  result  than  sterility,  as  serious  deformity  may  ])revent 
either  erection  or  sufficient  develo])ment  of  the  organ  to  permit 
intromission.  No  matter  how  great  the  deformity,  however,  the  in- 
dividual may  be  fruitful  if  circumstances  be  favorable,  so  long  as 
the  testicles  ;u"e   functionally  ])erfect. 

llic  author  is  of  opinion  llial  pcn'crsion  of  llie  qiiaHly  or 
Icsscuiiuj  of  the  qiiantitx  of  iJic  sex  Jioniionc  formed  in  llie  glands 
llial  produced  llic  parental  (jcnn  cell  or  sperm  cell — or  hath — is 
tJie  biologic  foioidation  of  lH)tIi  psycliic  and  pJiysical  aberrations  of 
sex  differentiation.  As  to  what  causes  the  defective  or  vicious 
hormone  sup])ly  in  the  ])arent,  this  also  nuist  be  theoretic.  It  pos- 
sibly is  a  defect  in  the  su])rarenals  or  in  the  anterior  lobe  of  the 
])ituitary  body  with  defective  sex  gland  development.  The  author 
believes  that  an}-  general  or  local  condition  which  impairs  the 
integrity  of  the  bioplasm  of  the  hormone-|)r()ducing  cells  in  the 
sex  glands  may  be  res])onsible  for  ])hysio-sexual  and  psycho-sexual 
aberrations.  Sexual  excesses.  s\])hilis — or  other  general  infections 
— might  reasonably  be  considered  as  ])ossible  general  causes. 

Physical  or  psychic  maternal  shock  probably  may  bring  about 
hormone  disturbance  and  consequent  maldeveloi)ment.  This  ma\- 
explain   certain    so-called   "maternal   impressions."" 

It  certainly  is  true  that  vitiated  blood  is  poor  material  for  the 
elaboration  of  normal  hormone  by  the  sex  glands  and,  without 
healthy  and  ])r()i)er  hormone  su])])ly,  it  is  reasonable  to  suppose 
that  the  ovule  and  spermatozoa  will  lack  the  nutritive  "])unch" 
necessar}-  to  com])lete  and  ])erfect  deve]o])ment.  If  the  author's 
77'^7«.'  be  correct,  sexual  peri'ersion  and  iwi'ersion — 7eith  or  ccilh' 
out  phxsicid  al'crratiotis — are  purely  biocheinic  in  orii^i)!,  and,  if 
taken  early,  susceptil'le  of  cure  by  implantation  of  sc.v  glands, 
thereby  adding  to  the  economy  during  the  period  of  sex  develop- 

—  16    - 


HERMAPHRODITISM 

meiif,  a  certain  quantity  of  a  nczv  and  better  quality  of  sex-hormone. 
The  author  is  convinced,  moreover,  that  there  is  great  advantage 
in  the  fact  tJiat  the  added  hormone  usually  is  an  alien  strain.  So 
logical  does  the  foregoing  seem  to  the  author,  that  he  believes 
that  a  certain  proportion  of  cases  of  perversion  and  inversion,  if 
treated  prior  to  adult  age,  are  hopeful  cases  for  the  procedure. 

What  could  be  more  logical  than  the  treatment  of  masculinity 
in  the  female  and  of  femininity  in  the  male,  by  large  and  constant 
doses  of  sex  hormone  of  the  corresponding  sex  through  the  medium 
of  implanted  glands  during  the  period  of  sex-development  and 
differentiation?  That  the  acquired  type  of  aberrant  physio-sexual 
differentiation  frequently  is  susceptible  of  cure  by  implantation 
seems  probable.  Later  on,  the  author  will  relate  a  case  that  is 
decidedly  in  point.     (Case  6,  Chapter  XL) 

Licompatibility  of  the  sex  hormones  due  to  biologically  unfit 
mating  may  have  much  to  do  with  teratologic  sex  aberrations.  This 
is  occult,  it  is  true,  but  possibly  is  an  important  factor  in  eugenics. 

That  a  primary  defect  in  the  quantity  and  quality  of  the  sex 
hormone  is  essentially  the  cause  of  certain  aberrant  types  of  phy- 
sio-sexual development — and  incidentally  of  their  attendant  pschyo- 
sexual  aberrations — is  fairly  conclusively  proven  by  the  facts  that : 
1st.,  Loss  of  the  ovaries  in  previously  normal  young  females  is 
followed  by  the  development  of  masculine  secondary  sex  char- 
acteristics. 2nd.,  The  same  principle  holds  good  in  the  loss  of  the 
testes  in  the  male,  secondary  female  sex  characteristics  developing. 
3rd.,  Successful  administration  of  the  appropriate  sex  hormone  is 
followed  in  greater  or  less  degree  by  a  return  to  the  normal  sec- 
ondary sex  characteristics.* 

The  author  believes  that  the  sex  hormone  aberration  theory 
of  sex  maldevelopment  is  not  incompatible  with  the  theory  of  the 
influence  of  pituitary  and  adrenal  cortex  hormone  on  the  primary 
development  of  the  sexual  organs.  Normal  sex  hormone  prob- 
ably is  primarily  essential  to  the.  development  of  the  ovum,  the 
other  hormones  coming  into  play  only  after  the  embryonic  develop- 
ment of  the  pituitary  body  and  adrenals  is  completed,  after  which 
the  endocrine  nutritive  cycle  is  established  and  the  hormones  work 
in  harmony  for  the  purposes  of  nutrition,  differentiation  and  de- 
velopment. 

*As  will   be   seen   later,    this  has   been  proved   by   the   author's   work   in    sex 
gland  implantation. 

—   17  — 


IMPOTENCE  AND   STERILITY 

Curiously  enough,  the  sex  hormone  theory  suggested  by  the 
author  is  not  inharmonious  with  certain  theories  of  the  Neo-Darwin- 
ian  school  of  biologists,  notably  Weismann's.  According  to  the 
latter,  the  theory  of  germinal  selection  can  be  applied  to  the  degen- 
eration of  organs. 

The  germ  (or  the  chromatic  matter  in  the  nucleus  of  the  germ)  is  com- 
posed of  tiny  particles  called  determinants,  each  of  which  has  its  cell,  or 
group  of  cells,  to  form  in  the  growing  organism.  These  determinants  them- 
selves feed  and  grow  in  the  ovary  and  are  subject  to  a  kind  of  struggle  for 
food.  Some  obtain  more  than  their  normal  share  of  nourishment,  and  this 
leads  to  increased  size  or  efficiency  of  the  parts  of  the  organism  which  they 
construct.  But  others  obtain  less  than  their  normal  quantity,  and  the  parts 
of  the  organism  which  they  build  are  of  diminished  strength. 

If  we  accept  as  the  underlying  determinant  principle  of  nutri- 
tion 1.  the  parental  individual  sex  hormone — modifying  the  ovule 
and  si)ermatozoa — 2.  the  combined  hormones  in  the  fructified  ovule 
— /.  e.,  the  ovum.  3.  the  maternal  hormones  furnished  by  the  ovary 
and  especially  by  the  corpus  luteum  of  pregnancy,  the  possible  re- 
lation of  perversions  of  the  sex  hormone  to  aberrations  of  sex  de- 
velopment and  differentiation  would  seem  to  have  excellent  biologic 
support. 

In  determining  the  sex  of  alleged  hermaphrodites  the  following 
points  require  consideration : — 

1.  The  character  of  the  voice. 

2.  The  development  of  the  mammae. 

3.  The  growth  or  absence  of  beard. 

4.  The  form  of  the  shoulders,  hips,  and  waist. 

5.  The  ]:)reseiice  or  otherwise  of  the  menses  or  vicarious  dis- 
charges. 

6.  The  character  of  sexual  desire.  In  respect  to  this  point 
the  occasional  co-existence  of  sexual  perversion  with  genital  de- 
formity should  be  given  its  due  meed  of  consideration.  Thus,  in 
a  case  in  which  difficulty  of  diagnosis  existed,  a  perverted  sexual 
affinity  for  the  same  sex  might  mislead  the  physician. 

7.  The  presence  or  absence  of  rudimentary  (or  perfect)  testes 
or   ovaries. 

8.  Tlie  form  of  the  sup])osed  clitoris  or  ])enis,  the  method  of 
attachment  of  its  prepuce,  and  the  absence  or  presence  of  per- 
foration in  its  glans. 

*•).     The    presence    or    absence    of    the    hymen    (rudimentary), 

—  18  — 


HYPOSPADIAS   AND   EPISPADIAS 

nymphae,  labia  majora,  or  bifid  scrotum,  as  the  case  may  be.  In 
cases  of  doubt  it  is  safest  to  regard  the  individual  as  a  female  until 
time  and  pubescence  have  settled  the  question. 

The  cases  of  imperfect  or  aberrant  sexual  differentiation  in- 
cluded under  the  head  of  sexual  perversion  obviously  are  more  dif- 
ficult to  study  than  those  in  which  the  aberration  is  of  a  purely 
physical  character.  This  is  especially  true  regarding  sapphic  love, 
or  sexual  affinity  of  female  for  female.  That  such  cases  are  fre- 
quent is  certain,  but  they  are  extremely  difficult  to  trace.  The 
confessional  of  the  family  physician  doubtless  might  offer  evidence 
of  a  clinical  character,  but  he  is  very  chary  of  airing  the  shortcom- 
ings of  his  patients  in  this  particular  direction. 

The  existence  of  this  abnormal  sexuality  can  be  explained 
only  by  aberrant  psychosexual  differentiation.  In  the  case  of  the 
male,  instances  are  so  common  that  the  subject  is  decidedly  trite. 
It  is  not  only  charity,  but  a  sense  of  justice  and  a  desire  to  lessen 
the  stigma  upon  human  nature,  that  impels  the  author  to  include 
typic  cases  of  sexual  perversion  under  the  head  of  aberrant  sexual 
differentiation,  and  to  attribute  the  condition  to  perverted  or  im- 
perfect evolutionary  development,  on  the  one  hand,  and  a  reversion 
of  type,  on  the  other.  To  understand  such  problems  it  is  neces- 
sary to  consider  the  sex  life  of  the  primordial  cell  and  the  prehuman 
ancestral  hermaphroditic  type  of  all  animal  life.  Sex  differentiation 
came  relatively  late  in  the  operations  of  biogenic  law.  Until  the  male 
principle  appeared  there  zvas  no  sex,  but  merely  se.vually  undifferen- 
tiated bioplasm  7vhich  multiplied  after  its  kind. 

CONGENITAL  DEFORMITIES  OF  THE  URETHRA. 

Hypospadias  and  Epispadias. 

These  comprise  practically  all  of  the  congenital  deformities  of 
the  urethra,  save  the  rare  cases  in  which  diverticula  or  duplicate 
channels  exist.  These  conditions  quite  generally  have  been  attrib- 
uted to  a  failure  of  development  in  intrauterine  life.  The  embryo 
being  practically  laid  down  primarily  in  two  longitudinal  sections — 
which  subsequently  became  fused  together  in  a  perfect  anatomic 
entity — it  is  obvious  that  failure  of  fusion  at  any  particular  point 
may  produce  congenital  deformity.  The  deformity  necessarily 
varies  in  kind  according  to  the  location  of  developmental  failure, 

—  19  — 


IMPOTENCE  AND   STERILITY 

and  its  degree  is,  of  course,  modified  by  the  extent  of  such  defect 
in  fusion.  It  seems  logical  to  infer  that  the  deformities  under  con- 
sideration are  the  results  of  failure  of  fusion  of  the  genital  furrow. 
It  is  the  normal  fusion  of  this  furrow  which  eventually  dififeren- 
tiates  the  sexes.  A  failure  of  development  results  in  an  approxima- 
tion to  the  male  or  female  according  to  the  degree  of  perfection  to 
which  embryonic  development  has  arrived  at  the  time  it  is  inter- 
fered with.  The  various  forms  of  failure  of  differentiation  have 
led  in  many  instances  to  confusion  in  the  determination  of  sex.  The 
subjects  of  hypospadias  and  epispadias— especially  the  former — 
therefore,  are  very  closely  associated  with  so-called  hermaphrodit- 
ism in  its  various  phases.  Failure  of  fusion  of  the  scrotum,  asso- 
ciated with  cryptorchidism,  rudimentary  development  of  the  penis, 
and  hypospadias,  represents  the  most  frequent  type  of  pseudo-her- 
maphroditism — the  type  that  most  often  masquerades  as  true  her- 
maphroditism. As  will  be  seen  later  on,  the  subject  of  sexual  per- 
version is  very  intimately  blended  with  urethral  deformities. 

Failure  of  embryonic  development  as  the  cause  of  urethral  de- 
formities recently  has  been  disputed.  Thiersch,  for  example,  and 
others  have  claimed  that  these  deformities  are  due,  not  to  imperfect 
embryonic  development,  but  to  atresia  of  the  urethra,  with  subse- 
quent rupture  behind  the  point  of  obstruction.  Numerous  argu- 
ments have  been  advanced  in  supi)ort  of  this  view  by  various  inves- 
tigators ;  dilation  of  the  ureter  and  pelvis  of  the  kidney,  such  as  is 
often  found  in  hydronephrosis,  and  the  presence  of  cicatricial  tissue 
being  the  chief  points. 

The  author  cannot  accept  the  foregoing  theory ;  there  are  too 
many  analogous  conditions  that  almost  necessarily  must  develop 
along  the  same  lines  as  urethral  deformities  and  which  cannot 
be  explained  u])on  a  simple  mechanic  basis.  The  principal  argu- 
ment against  the  theory  is  the  general  defective  development  as- 
sociated with  urethral  deformities,  there  being  not  only  a  failure 
of  physical,  but  also  of  psychosexual  differentiation  in  a  large  pro- 
portion of  cases.  It  is  not  necessary  to  resort  to  a  mechanic  ex- 
])lanation  of  the  intimate  association  of  congenital  diseases  of  the 
kidney  and  ureter  found  coincidentaly  with  all  urethral  deformities. 
The  same  aberration  and  failure  of  embryonic  development  are 
sufficiently  explanatory  in  both. 

]I^•l'OS^AI)lAS. —  In  this  condition  the  deficiency  of  development 

—  20  — 


SEX    ML'TII.ATIOXS 

is  situated  alon,^'  the  Hoor  of  the  urethra,  and  is  associated  witli 
a  defective  penile  development  proportionate  to  the  degree  of  the 
hypospadias.  The  tn-ethra  may  open  at  any  ])oint  from  the  frcnwin 
prcpiitii  to  the  ])erinenm  ;  the  farther  hack  the  opening,  the  greater 
the  failure  of  physical  ditl'erentiation  of  sex.  In  the  majority  of 
instances  the  deformit}'  is  >light.  the  urethra  opening  just  behind 
or  at  the  side  of  the  frenum.  Ca>es  in  which  the  opening  is  located 
posterior  to  the  peno-scrotal  angle  are  relativel}'  rare.  In  the  sinipler 
varietv  there  is.  as  a  rule,  no  great  inconvenience  resulting  froiu 
the  conditi(jn.  soiling  of  the  clothing  with  urine  and  sterility  being 
the  principal  features  of  annoyance.  'i'hese  disagreeable  results 
increase  in  degree  ])r(i])orti()nate  to  the  extent  (jf  the  deformity. 

lu^isi'ADiAs. — l^pispadias  is  rarer  than  hypos])adias,  is  most 
often  fotnid  in  the  female,  and  generally  is  associated  with  exstrophy 
of  the  bladder.  It  sometimes  is  associated  with  congenital  absence 
of  the  sym])hysis  ptibis.  and  so  often  is  coml)ined  with  ectopia 
I'csiccc  that  its  consideration  ])roperly  falls  inider  the  head  of  con- 
genital deformities  of  the  bladder.  There  are  some  rare  cases 
in  which  there  is  a  simple  epis])adias  without  exstrophy. 

The  (operative  management  of  urethral  deformities  does  not 
come  within  the  scope  of  this  work.  It  is  r)bvious.  however,  that  in 
so  far  as  a  given  deformity  interferes  with  ])otency  or  fertility, 
operation  is  indicated.  The  author  has  had  the  good  fortune  to 
successfully  o])erate  on  a  ntimber  of  cases  of  this  kind. 

.\c<jriRi;i)   1  )i;i'()KM  i  rii:s. 

Ac(|viired  tirethral  deformities  and  traumatic  accidents  to  the 
l)eni>  and  tirethra.  or  to  the  tirethra  alone,  are  occasional  causes  of 
impotence.  Cases  of  nnuilation  of  the  penis  b\'  jeaalous  women 
are  more  fre([tient  than  generally  is  su])])osed.  The  aiuhor  ha^ 
met  with  several  cases  of  c()iu])lete  amputation.  Otiite  recentlv  also, 
a  ca<e  of  mutilation  of  the  testes  ])roduced  through  a  sinn'lar  agenc\' 
came  tmder  his  observation. 

The  ])S_\chol()gy  of  cases  of  genital  injur\-  1)\-  criminal  assaults 
varies.     As  originallv   frjrnudated  1)\'  the  author,*  thev  are: 

1. — Sini])le  jealotis}-.  Women  sometimes  injtire,  not  onlv  tlu' 
offending  mate,  bitt  also  the   female   ri\-al.   making  the  genitals  the 

*  New  V(irk  ^r.■.l.  .jMur..  l-'d..  :;.    liOi'. 


IMPOTENCE    AXl)    STl':RILrrY 

object  of  assault.  The  male  often  makes  the  genital  organs  the 
objective  i)oint  of  assault  U])on  a  rival.  'J'he  dominant  idea  in  most 
cases  simply  is  revenge. 

2. — The  desire  to  deprive  a  rival  of  what  seems  to  the  jealous 
person  the  chief  ])t)int  of  interest  to  the  rival. 

3. — A  desire  to  punish  the  one  at  whose  hands  the  assailant 
has  suffered  iniiu-v. 


C'a^c  i)f  amputation  of  [icnis  1)y  a  jealous  wife. 


4. — A  "dog  in  the  manger''  sentiment.  I-)Oth  women  and  men 
have  been  known  to  commit  sex  nmtilation  on  persons  in  whom 
they  no  longer  were  interested. 

5. — The  desire  to  protect  oneself  from  future  encroachment 
on  one's  sexual  rights.  A  comparatively  recent  famous  Western 
case  is  in  ])oint. 

6. —  Insane  impulse. 

7. —  Reversionary  instinct,  resulting  in  sadism.  Apro])OS  of 
this  i)oint.  the  attack  of  the  female  spider  and  of  the  female  Mantis 
rclif/iosa  U])on  the  male  after  copulation  are  illustrations. 

Cask. — X,  referred  to  the  ruithor  ])y  tlie  late  Dr.  H.  F.  Stcerc,  of  Chicago. 
.\ti  honest,  Iiard  workint;.  decent  llolieniian  incurred  tlic  jealousy  of  In's  wife, 

—  22  -  - 


PRECOCIOUS    SEXUALITY 

through  what  she  chose  to  believe  was  indifference  due  to  attentions  to  other 
women.  So  far  as  the  author  was  able  to  determine,  the  woman  was  abnor- 
mally developed  sexually  and  the  "indifference"  of  the  unfortunate  victim 
of  her  jealousy  and  vindictiveness  was  due  merely  to  the  physical  fatigue 
incidental  to  his  occupation,  which  was  that  of  a  laborer. 

About  3  o'clock  on  the  night  of  October  15,  1911,  while  X  was  sleeping 
soundly,  Mrs.  X  procured  a  razor  and  completely  amputated  his  penis,  about 
an  inch  from  the  pubic  cymphysis.  The  hemorrhage  was  very  profuse,  and 
as  Dr.  Steere,  who  was  called  to  attend  the  case,  did  not  arrive  on  the  scene 
for  about  forty  minutes,  he  found  the  patient  in  semi-syncope  and  almost 
exsanguinated.  The  amputated  organ  was  found  hanging  by  a  narrow  strip 
of  integument. 

After  severing  the  skin  and  removing  the  injured  member,  the  doctor 
trimmed  the  stump,  leaving  the  urethra  longer  than  the  stump.  He  then  split 
the  "cuff"  of  the  urethra  and  stitched  it  partly  over  the  stump  to  form  a 
pseudo-meatus.  A  small,  soft  rubber  catheter  No.  17  F.  was  left  in  the 
bladder.'^  Healing  was  prompt,  and  the  author  was  privileged  to  exhibit  the 
case  at  his  clinic  three  weeks  later. 

Deformity  of  the  penis  due  to  chronic  inflammation  of  the  cor- 
pora cavernosa  not  infrequently  produces  impotence.  The  author 
so  often  has  observed  this  condition  in  conjunction  with  arterio- 
sclerosis, that  he  has  come  to  believe  that  this  condition  of  the 
blood  vessels  frequently  is  of  etiologic  importance. 

Precocious  Sexuautv. 

In.  rare  instances  young  children  exhibit  sexual  precocity — 
both  as  to  physical-sexual  and  psycho-sexual  development.  These 
cases  are  easy  of  recognition  but  difficult  to  explain.  The  sex  syn- 
drome consists  of  ]:»rematurely  enlarged  sexual  organs  and  develop- 
ment of  pttbic  hair  and,  in  the  male,  excessive  general  hair  growth 
with  corresponding  voice  change,  precocious  sexual  desire  in  both 
sexes,  notably  in  the  male,  and  abnormally  early  menstruation  in 
the  female.  Associated  with  these  sex  manifestations  are  pre- 
cociously mature  thought  and  speech  habit,  and  general  bodily 
overgrowth,  a  child  of  five  or  six  years  of  age  presenting  the 
physical  ap])earance  of  one  of  eleven  or  twelve. 

The  cause  of  sexual  precocity  is  obsctu'e,  but  has  been  asserted 
to  be  an  impairment  of  the  functions  of  the  pineal  gland,  the  hor- 
mone of  which,  it  is  claimed,  normallv  inhibits  sextial  growth  until 


*  The  retained  catheter  slipped  into  the  bladder.     The  author  found  it  with 
the  cy.stoscope  six  weeks  later  and  removed  it  with  a  lithotrite  per  urethram. 

—  23  — 


IMPOTENCE  AND   STERILITY 

puberty.  This  theory  is  based  upon  cases  of  tumor  of  the  pineal 
gland  in  which  the  syndrome  described  existed.  Inasmuch,  how- 
ever, as  feeding  pineal  gland  to  young  animals  produces  a  similar 
syndrome,  the  only  explanation  of  the  phenomena  seems  to  the 
author  to  be  a  derangement  of  the  equilibrium  of  the  endocrine 
nutritive  cycle,  which  may  be  produced  by,  1st,  increase,  2nd, 
diminution,  3rd,  vitiation  of  the  pineal  endocrine  secretion.  In  any 
event,  the  administration  of  pineal  substance  at  present  must  stand 
on  purely  tentative  and  empirical  ground. 

That  a  pernicious  heredity — involving  especially  syphilis  and 
neuro-degeneracy — possibly  may  underlie  sexual  precocity  hardly 
will  be  disputed. 


24 


CHAPTER    II. 
Diseases  of  the  Sexual  Function  and  Instinct. 

General  Considerations. — The  sexual  function  is  animated 
by  the  most  vital  of  all  animal  instincts.  When  made  to  subserve 
its  real  purpose — procreation — sexual  desire  fundamentally  is  the 
most  disinterested  of  the  purely  animal  appetites.  Granting  that 
it  is  a  mere  differentiation  of  its  ancestral  instinct,  hunger,  its  ulti- 
mate object  is  higher  than  that  of  the  parent  appetite.  The  ultimate 
object  of  hunger  is  the  preservation  of  the  life  of  the  individual, 
while  that  of  the  sexual  passion  is  the  preservation  of  the  species. 
The  fact  that  the  individual  derives  pleasure  from  the  sexual  act 
detracts  not  at  all  from  the  unselfishness  of  its  object,  so  far  as  its 
relation  to  the  grand  scheme  of  Nature  is  concerned.  The  sexual 
passion  is  no  more  open  to  impeachment  on  the  ground  of  selfish- 
ness than  is  the  fundamental  instinct  of  hunger.  Both  are  alike 
productive  of  pleasure  in  their  gratification ;  both  are  alike  subject 
to  abuse  by  those  who  pursue  the  pleasure  of  gratification  of  the 
animal  appetites  with  a  total  disregard  of  their  natural  objects. 
There  are  relatively  few  who  "eat  to  live ;"  those  who  live  to  eat 
are  legion.  The  proportion  of  human  beings  who  copulate  for  pro- 
creative  purposes  is  very  small  as  compared  with  those  for  whom 
the  sexual  act  is  the  axis  upon  which  the  world  revolves. 

As  regards  his  sexual  ethics,  man  probably  has  retrograded 
from  the  primal  stock  from  which  he  descended — or  ascended,  ac- 
cording to  the  point  of  view.  Those  of  the  lower  animals  that 
modern  human  society  pretends  to  imitate — the  monogamous  types — 
are  vastly  superior  to  man  from  the  sexual  stand-point.  The  pair- 
ing of  animals,  even  though  it  be  for  a  limited  period  only,  means 
something.  The  unwritten  law  is  unbroken.  With  human  beings, 
the  contract  involved  in  the  pairing  system  legitimatized  in  monog- 
amous social  organizations,  means  much  or  little,  according  to  the 
moral  bent  and  sexual  capacity  of  the  individual. 

The  sexual  immorality  and  perverted  sexual  physiology  of  the 
human  race  generally  is  discussed  from  the  stand-point  of  morals, 

—  25  — 


IMPOTENCE  AND   STERILITY 

with  a  total  disregard  for  common  sense,  to  say  nothing  of  natural 
law.  It  does  not  seem  to  occur  to  the  moralist  and  would-be  social 
reformer  that  there  is  an  organic  basis  for  sexual  infractions  of 
moral  and  physiologic  law — still  less  is  it  understood  that  the  moral 
code  is  a  relative  matter,  devised  to  subserve  some  selfish  motive 
or  other,  with  a  total  disregard  for  natural  law. 

The  question  of  the  relative  social  value  and  safety  of  monog- 
amy and  polygamy  is  too  broad  for  discussion  here.  That  monog- 
amy, from  a  sociologic  stand-point,  irrespective  of  arbitrary  moral 
codes,  is  best  adapted  to  our  own  social  necessities,  is  admitted. 
That  it  is  in  conformity  with  natural  law  so  far  as  the  human 
race  is  concerned,  the  author  does  not  believe.  Man,  by  nature, 
instinct,  and  physiologic  demand — and  incidentally,  as  a  cog  in 
the  machinery  of  biologic  "economics" — is  a  polygamous  animal. 
Monogamy,  like  many  other  social  customs,  is  a  sacrifice  of  natural 
law  to  personal  and  social  selfishness  and  expediency.  The  sexual 
immorality  and  perverted  sexual  physiology  of  man — taking  our 
own  moral  code  as  the  standard — are  the  result  of  the  battle  of 
social  with  natural  man. 

If  man  basically  is  a  monogamous  animal,  nature  builds  poorly 
and  is  an  unreliable  physiologic  conservator.  It  is  evident  that,  in- 
asmuch as  the  object  of  the  sexual  function  is  the  preservation  of 
the  species,  the  act  of  copulation  should  be  performed  only  at  such 
times  and  under  such  circumstances  as  subserve  that  object.  In 
the  lower  monogamous  animals  copulation  and  desire  apparently 
both  cease  with  impregnation.  This  does  not  hold  good  with  the 
human  species.  Even  with  polygamous  animals  the  beginning  of 
l)reeding  heralds  the  cessation  of  copulation.  The  domestic  fowl — 
whose  polygamy,  by  the  way,  originally  was  acquired  through  forced 
adaptation  to  the  commercial  demands  of  its  human  proprietors — 
presents  a  shining  example  of  the  relative  decency  of  polygamy 
so  far  as  the  female  is  concerned. 

To  even  hint  that  the  female  of  the  human  species  was  origin- 
ally designed  for  a  monogamous  animal  perhaps  is  dangerous,  after 
expressing  tlie  opinion  that  the  male  is  polygamous  by  nature,  yet 
the  author  unhesitatingly  affirms  that  view.  A  certain  proportion 
of  females  experience  sexual  desire  even  during  gestation,  but  the 
fact  remains  that  desire  is  relatively  feeble  in  women,  as  a  rule, 
and  normally  coittis  should  be  repugnant  to  the  female  during  gesta- 

—  26  — 


DISEASES  OF  THE  SEXUAL  FUNCTION  AND  INSTINCT 

tion.  Where  it  is  not,  there  simply  is  hereditarily  perverted  sexual 
physiology  due  to  the  unphysiologic  approaches  of  the  male  prac- 
ticed from  time  immemorial,  or  local  irritation  from  disease.  So- 
cially it  is  not  well  that  there  should  be  "one  law  for  the  man  and 
another  for  the  woman,"  but  such,  apparently,  was  Nature's  original 
intention,  however  much  it  has  been  subverted  to  social  demands 
and  individual  selfishness.  That  nature  designed  the  sexual  function 
of  the  human  male  to  lie  latent  during  the  pregnancy  and  parturi- 
tion of  a  given  mate  is  a  reflection  on  the  efficiency  of  biologic  law. 

While  in  no  sense  desiring  to  apologize  for  the  sexual  im- 
morality and  perverted  sexual  physiology  of  the  human  race,  the 
author  firmly  believes  that  much  of  it  is  explicable  upon  the  fore- 
going grounds.  And,  the  sooner  we  face  the  issue  the  more  in- 
telligently will  we  be  able  to  meet  sex  problems.  This  view  is  espe- 
cially pertinent  with  respect  to  the  etiology  of  sexual  excess.  Alan 
and  woman  alike  have  suffered  from  abrogation  of  natural  law. 
It  is,  of  course,  admitted  that  polygamy  as  practiced  in  the  harems 
of  the  Orient  is  likewise  productive  of  perverted  sexual  physiology  ; 
but  the  basic  sexual  instinct  of  the  human  male  is  not  at  all  respon- 
sible for  his  abuse  of  the  sexual  function. 

Ignorance  of  sexual  physiology  is  one  of  the  fundamental  causes 
of  disease  of  the  sexual  function,  and  especially  of  those  produced 
by  masturbation.  Society  imposes  certain  sexual  restrictions  upon 
the  human  race,  while  at  the  same  time  discountenancing  the  ac- 
quirement of  knowledge  of  the  sexual  function  and  its  object.  So- 
ciety also  furnishes  the  w^orst  possible  environment  for  its  own 
moral  ends.  The  natural  desires,  especially  of  the  male,  are  excited 
by  various  impressions  to  which  he  is  exposed  until  sexual  irritabil- 
ity inevitably  results.  The  individual  is  then  asked  to  be  chaste  and 
virtuous,  notwithstanding  the  fact  that  society  furnishes  him  with 
an  environment  that  would  lead  one  to  infer  that  virtue  is  an  un- 
known quantity.  Society  has  not  changed  its  moral  law — written 
or  unwritten — pari  passu  with  its  advancing  wickedness.  It  is  not 
so  many  years  since  such  books,  pictures,  and  plays  as  are  tolerated 
to-day  were  tabooed.  The  movies  are  "censored"  by  long  haired 
men  and  short  haired  women,  whilst  the  uncensored  burlesque  show 
presents  "attractions"  that  would  shock  the  sensibilities  of  a  tender- 
loin parrot.  Latter-day  art,  literature,  and  stage  furnish  an  at- 
mosphere  of   sexual   immorality  to   which,   sooner  or  later,   every 

—  27  — 


IMPOTENCE  AND   STERILITY 

youth — male  or  female — is  inevitably  exposed.  Tabooed  books 
and  pictures  are  not  very  dangerous ;  the  person  who  indulges  in 
them  knows  full  well  that  such  things  are  evil.  Trilby,  the  fad, 
did  more  damage  to  the  sexual  morale  of  society  than  all  the  tabooed 
obscene  books  ever  written.  Clandestine  vice,  known  to  be  under 
the  ban,  is  honest  enough,  to  say  the  least.  Vice  thinly  veiled,  or 
gilded  over  by  the  mawkish  sentiment  engendered  by  Trilby  pink 
teas  and  yellow  breakfasts  and  apologized  for  by  social  faddists,  is 
insidious  and  deadly.  A  Magdalen  repentant  has  ever  been  a  lesson 
in  morality,  but  the  naive  admission  of  Trilby  that  she  had  had 
a  certain  limited  number  of  lovers  hardly  can  be  admitted  to  Mag- 
dalenic  literature. 

The  example  often  set  by  celebrities  in  their  private  (sic)  lives, 
tolerated  as  it  is  by  society,  is  a  very  dangerous  factor  in  the  pro- 
mulgation of  sexual  immorality.  Society  proclaims  from  the  house- 
tops :  "Thou  shalt  not,"  and  then  whispers  softly  in  the  ear  of  the 
favored  ones :  "Of  course,  I  don't  mean  geniuses  like  you."  And 
the  favored  and  talented  few  go  on  and  on,  even  exploiting  their 
sexual  derelictions  for  advertising  purposes. 

The  public  press  must  come  in  for  its  share  of  blame  in  the 
promulgation  of  pernicious  sexual  impulses  among  the  young. 
Sexual  immorality  is  either  condoned  or  discussed  in  a  tone  of  flip- 
pancy that  amounts  to  condonation.  To  the  minds  of  the  young 
and  inexperienced,  sexual  license  would  seem  to  be  the  unwritten 
code  of  modern  society. 

Is  it  fair  that  society  should  demand  that  the  young  should 
remain  in  ignorance  of  the  physiologic  side  of  sexual  matters, 
while  its  vicious  aspects  are  paraded  in  all  their  nakedness?  How 
difficult  the  task  of  the  mother  who  endeavors  to  inculcate  purity 
in  the  minds  of  her  daughters !  And  how  much  more  difficult  the 
task  of  the  father  who  endeavors  to  keep  his  son  ofif  the  rocks 
and  shoals,  not  by  teaching — often  not  by  example — but  by  dis- 
cipline ! 

The  sum-total  of  results  is  that  the  growing  lad  comes  to  re- 
gard sexual  ])urity  as  something  to  be  ashamed  of,  and  female 
virtue  as  extremely  out  of  fashion.  Young  girls,  too,  are  likely 
to  regard  with  tolerant  eyes  those  moral  lapses  which  are  com- 
mon to  social,  literary,  and  stage  lions.  The  resultant  evils  are 
sufficiently  obvious. 

—  28  — 


GENERAL   CONSIDERATIONS 

Inasmuch  as  society  practically  has  thrown  down  all  but  the 
traditional  theoretic  barriers  between  sexual  purity  and  impurity, 
it  would  seem  that  abuses  of  sexual  physiology  can  be  combated  only 
upon  purely  physical  grounds.  In  a  certain  sense,  too,  the  sel- 
fishness of  the  individual  must  be  appealed  to.  Young  lads  should 
be  taught  that  masturbation  is  dangerous  to  their  physical  well- 
being — that  they  never  can  become  as  perfect  men,  morally,  phys- 
ically, or  intellectually,  if  they  indulge  prematurely  in  any  sort  of 
exercise  of  the  sexual  function  as  they  will  if  they  remain  continent. 
The  young  lad's  instinct  of  self-preservation  will  accomplish  much 
more  than  lessons  in  morality  that  momentarily  are  being  con- 
tradicted by  scenes,  persons,  and  incidents  about  him.  A  most 
profound  impression  may  often  be  made  by  stating  that  early  in- 
dulgence blunts  sexual  sensibility,  and  thus  to  a  certain  degree 
deprives  the  individual  of  the  legitimate  pleasures  of  his  later 
matrimonial  life.  And  this  statement  is  by  no  means  exaggerated. 
It  is  probable  that  no  man  who  has  indulged  in  sexual  congress  or 
masturbation  to  any  degree  prior  to  full  maturity  is  ever  possessed 
of  normal  sexual  sensibility  in  later  life. 

The  psychic  effect  of  early  sexual  indulgence  and  masturbation 
is  even  more  deleterious  than  the  purely  physical.  Youth  is  imagina- 
tive, as  well  as  hyperesthetic,  and  its  pleasures  are  consequently 
relatively  keen.  The  sexual  experiences  of  youth  so  mold  the 
psychosexual  centers  that  a  standard  is  set  for  all  future  sexual 
experiences.  The  adult  life  of  the  individual  is  often  devoted  to  the 
pursuit  of  a  sexual  ideal  that  exists  only  in  his  brain — an  ideal 
that  is  but  a  memory  of  his  younger  and  more  Impressionable 
days.  This  ideal  is  the  will-o'-the-wisp  that  leads  many  men  into 
sexual  immorality  and  excess. 

In  brief,  while  preaching  morality  to  youth,  it  were  well  to 
give  it  "a  reason."  Wise  counsel  and  intelligent  instruction  of  young 
lads  in  sexual  matters  might  do  more  for  the  morals  of  society  than 
any  amount  of  preaching. 

Much  has  been  said  of  the  evils  of  quack  literature  in  pollut- 
ing the  minds  of  the  young,  still  more  has  been  said  of  the  harpy- 
like proclivities  of  the  quack.  There  is,  however,  something  to  be 
said  on  the  other  side  of  the  question.  There  is  a  "soul  of  good  in 
things  evil."  ■Many  lads  would  go  on  in  their  evil  ways  indefinitely 
did  they  not  stumble  upon  quack  literature,  which,  while  exaggerat- 

—  29  — 


IMPOTENCE  AND   STERILITY 

ing  the  evils  of  masturbation  and  sexual  excess,  none  the  less  sounds 
the  first  note  of  warning  they  ever  have  received.  The  profession 
largely  is  responsible  for  this,  by  crying  down  any  attempt  on  the 
part  of  scientific  men  to  impart  knowledge  of  sexual  matters  to 
the  laity.  Why  the  profession  should  join  the  ignorant  public  in 
tabooing  sexual  knowledge  is  a  mystery,  quite  as  much  so  as  a  great 
deal  of  other  cant  and  hypocrisy  that  has  pervaded  the  medical 
profession  from  time  immemorial.  So-called  medical  ethics  has 
done  more  to  foster  quackery  than  to  prevent  it.  And  the  public 
smiles  derisively  at  a  profession  which,  after  years  of  travail,  will 
tolerate  "practice  limited  to  diseases  of  women"  on  professional 
cards ;  yet  would  roll  up  its  eyes  like  a  dying  rabbit  should  it  per- 
chance run  across  a  card  inscribed,  "diseases  of  men  only."  Pre- 
cisely what  phase  of  sentiment  elevates  a  woman  with  a  leucorrhea 
to  a  higher  plane  than  that  which  a  man  with  spermatorrhea  oc- 
cupies is  one  of  the  things  which,  as  Dundreary  says,  "no  fellow 
can  find  out."  Irrespective  of  cause,  it  is  a  deplorable  fact  that 
the  regular  profession  is  woefully  ignorant  and  culpably  negligent 
regarding  the  sexual  ailments  of  its  clientele. 

The  respectable  physician  still  is  laughing  at  the  complaints 
of  men  who  consider  themselves  impotent,  on  the  one  hand,  and 
prescribing  virgins  for  broken-down  roues  and  sexual  wrecks,  on 
the  other.  The  fact  that  the  virgins  are  to  be  sacrificed  on  Hymen's 
altar  satisfies  the  medical  imbecile  who,  like  the  ostrich,  has  his 
head  in  the  sand,  and  the  sacrifice  at  the  same  time  conforms  with 
social  demand.  The  impotent  man  should  receive  intelligent  advice 
from  the  general  practitioner.  The  man  who  is  unable  to  copulate 
is  face  to  face  with  a  grim  reality.  Whether  psychic  or  not,  his 
impotence  is  a  material  fact  of  which  he  is  only  too  keenly  con- 
scious. As  for  the  virgins  who  daily  are  prescribed  as  placebos  or 
panaceas,  it  is  high  time  they  were  represented  at  court.  The 
remedy  lies  with  the  profession.  The  sexual  organs  and  functions 
are  the  noblest  attributes  of  man,  and  their  diseases  are  quite  as 
worthy  of  intelligent  study  and  considerate  treatment  as  aflfections 
of  other  organs.  False  modesty  and  mawkish  sentiment  have  no 
place  in  scientific  medicine.  At  present,  the  ignorance  and  mock 
prudery  of  a  large  proportion  of  the  profession  is  absolutely  sicken- 
ing. But  matters  are  improving.  One  can  write  upon  sex  hygiene 
nowadays,  without  running  the  risk  of  professional  ostracism. 

—  30  — 


CHAPTER    III. 

Sexual  Perversion  and  Inversion. 

The  subject  of  sexual  perversion. — Contrdre  Sexuale  Bmpfin- 
dung, — although  a  disagreeable  one  for  discussion,  demands  the  at- 
tention of  the  scientific  physician,  and  is  of  great  importance  in  its 
social,  medical,  and  legal  relations.  J.  G.  Kiernan,  in  discussing 
the  hypothetic  dependence  of  the  Whitechapel  murders  upon  per- 
versions, says : — 

The  subject  may  seem  to  trench  on  the  "prurient,"  which  in  medicine 
does  not  exist,  since  "science,  like  fire,  purifies  everything,"  and  what  Macau- 
lay  calls  "the  mightiest  of  human  instincts"  is  too  intimately  related  to  the 
physical  basis  of  human  weal  and  woe  for  any  physician  prudishly  to  ignore 
any  of  its  phases. 

Until  a  comparatively  recent  date  the  subject  has  been  studied 
solely  from  the  standpoint  of  the  moralist,  and,  from  the  indispo- 
sition of  the  scientific  physician  to  study  them,  the  unfortunate 
class  of  individuals  who  are  characterized  by  perverted  sexuality 
have  been  viewed  in  the  light  of  their  moral  responsibility  rather 
than  as  victims  of  a  physical,  and  incidentally  of  a  psychic,  defect. 
It  certainly  is  much  less  humiliating  to  us  as  atoms  of  the  social 
fabric  to  be  able  to  attribute  the  degradation  of  these  poor  un- 
fortunates to  a  physical  cause  than  to  a  willful  viciousness  over 
which  they  have,  or  ought  to  have,  volitional  control.  Even  to  the 
moralist,  there  should  be  much  satisfaction  in  the  thought  that  a 
large  class  of  sexual  perverts  are  physically  abnormal  rather  than 
morally  leprous.  It  often  is  difficult  to  draw  the  line  of  demarkation 
between  physical  and  moral  perversion.  Indeed,  the  one  so  often 
is  dependent  upon  the  other  that  it  is  doubtful  whether  it  were 
wise  to  attempt  the  distinction  in  many  instances.  But  this  does  not 
afifect  the  cogency  of  the  argument  that  the  sexual  pervert  is  gen- 
erally a  physical  aberration — a  htsns  natnrcc. 

KrafiPt-Ebing  expresses  himself  upon  this  point  as   follows: — 

In  former  years  I  considered  contrdre  Sexuale  Empflndung  as  a  result  of 

neuropsychic  degeneration,  and  I  believe  that  this  view  is  warranted  by  more 

—  31  — 


IMPOTENCE  AND   STERILITY 

recent  investigations.  As  we  study  into  the  abnormal  and  diseased  condi- 
tions from  which  this  malady  results,  the  ideas  of  horror  and  criminality 
connected  with  it  disappear,  and  there  arises  in  our  minds  the  sense  of  duty 
to  investigate  what  at  first  sight  seems  so  repulsive,  and  to  distinguish,  if 
may  be,  between  a  perversion  of  natural  instincts  which  is  the  result  of  disease 
and  the  criminal  offences  of  a  perverted  mind  against  the  laws  of  morality 
and  social  decency.  By  so  doing  the  investigations  of  science  will  become 
the  means  of  rescuing  the  honor  and  re-establishing  the  social  position  (sic) 
of  many  an  unfortunate  whom  unthinking  prejudice  and  ignorance  would 
class  among  depraved  criminals.  It  would  not  be  the  first  time  that  science 
has  rendered  a  service  to  justice  and  to  society  by  teaching  that  what  seem 
to  be  immoral  conditions  and  actions  are  but  the  results  of  disease. 

In  every  community  of  any  size  there  is  a  colony  of  male  sexual 
perverts ;  they  are  usually  known  to  each  other,  and  are  likely  to 
congregate  together.  At  times  they  operate  in  accordance  with 
some  definite  and  concerted  plan  in  quest  of  subjects  wherewith 
to  gratify  their  obnormal  sexual  impulses.  Often  they  are  char- 
acterized by  effeminacy  of  voice,  dress,  and  manner.  In  a  general 
way,  their  physique  is  likely  to  be  inferior — a  defective  physical 
make-up  being  quite  general  among  them,  although  exceptions  to 
this  rule  are  numerous. 

Sexual  perversion  is  more  frequent  in  the  male ;  women  usually 
fall  into  perverted  sexual  habits  for  the  purpose  of  pandering  to  the 
depraved  tastes  of  their  patrons  rather  than  from  instinctive  im- 
pulse. Exceptions  to  this  rule  occasionally  are  seen.  For  example, 
the  instance  of  a  woman  of  perfect  physique,  who  is  not  a  pro- 
fessional prostitute,  but  moves  in  good  society,  who  has  a  fond- 
ness for  women,  never  being  attracted  to  men  for  the  purpose  of 
ordinary  sexual  indulgence,  but  for  perverted  methods.  The  phy- 
sician rarely  has  his  attention  called  to  these  things  and,  when  evi- 
dence of  their  existence  is  placed  before  him,  he  is  likely  to  receive 
it  with  skepticism.  He  regards  the  subject  as  something  verging 
on  Miinchausenism,  or,  if  the  matter  seem  at  all  credible,  he  sets 
it  aside  as  something  unholy  with  which  he  is  not  or  should  not  be 
concerned.  It  is,  indeed,  not  to  be  wondered  at  that  the  physician, 
who  so  often  views  with  pessimistic  eyes  the  human  animal,  should 
be  reluctant  to  add  to  his  store  of  contempt.  The  man  about  town 
very  often  is  an  fait  in  these  matters  and  can  give  very  valuable 
information.  Indeed,  witnesses  enough  can  be  found  to  convince 
the  tnost  skeptical. 

—  32  — 


SEXUAL   PERVF.RSrON    AND    INVERSION 

Sexual  i)tr\ersioii  may  best  be  defined,  in  a  »eneral  way,  as 
the  possession  of  impulses  to  sexual  gratification  in  an  abnormal 
manner,  with  a  partial  or  complete  apathy  toward  the  normal 
method. 

The  affection  presents  itself  in  several  forms,  which  may  be 
tabulated  as  follows: — 


I.  Congenital     and    per- 
haps hereditary  sex- : 
ual  perversion. 


II.  Acquired  sexual  per-, 
version. 


(a)  Sexual  perversion,  i.  c,  imperfect  psycho- 
sexual  dififerentiation,  without  defect  of 
structure  of  sexual  organs. 

(b)  Sexual  perversion  with  defect  of  genital 
structure :  e.  g.,  hermaphroditism. 

(c)  Sexual  perversion  with  obvious  defect  of 
cerebral  development :  e.  g.,  idiocy. 

(o)  Sexual  perversion  from  pregnancy,  the  meno- 
pause, ovarian  disease,  hysteria,  etc. 

{b)  Sexual  perversion  from  acquired  cerebral 
disease,  with  or  without  recognized  in- 
sanity. 

(c)   Sexual  perversion  (?)  from  vice. 

{d)  Sexual  perversion  from  overstimulation  of 
the  nerves  of  sexual  sensibility  and  the 
receptive  sexual  centers  incidental  to  sex- 
ual excesses  and  masturbation. 

When  the  author's  classification  as  above  presented  first  ap- 
peared, it  was  by  no  means  cordially  received,  its  practicality  being 
overlooked.  Its  adoption  by  Havelock  Ellis,  who  asserts  its  su- 
periority to  KrafFt-Ebing's  classification,  was  extremely  gratify- 
ing. 

As  regards  the  clinical  manifestations  of  the  disease,  sexual 
perverts  may  be  classified  as:  (a)  those  having  a  predilection 
(affinity)  for  their  own  sex— homosexuality ;  {h)  those  having 
a  predilection  for  abnormal  methods  of  gratification  with  the  op- 
posite sex;  (c)  those  affected  with  bestiality.  Instances  of  all  these 
different  varieties  have  been  observed. 

It  hardly  is  necessary  to  say  that  the  sexual  pervert  is  by  no 
means  a  modern  institution.  Sexually-perverted  conduct  evidently 
characterized  some  of  the  ancient  orgies.  It  is  certain  that  sexual 
perversion  w'as  prevalent  in  the  time  of  Nero.  The  author  is  not 
aware  that  attention  has  hitherto  been  called  to  the  Scriptural  evi- 
dence of  its  ancient  existence.     If,  however,  Scriptural  chronology 

—  33  — 


IMPOTENCE  AND   STERILITY 

be  correct,  it  was  recognized  at  least  as  early  as  a.  d.  60.  Positive 
proof  of  this  is  seen  in  the  Epistle  of  Paul  to  the  Romans:  Chap- 
ter I ;  24,  26,  27,  and  28  verses.    The  text  reads : — 

Wherefore  God  also  gave  them  up  to  uncleanness  through  the  lusts  of 
their  own  hearts,  to  dishonor  their  own  bodies  between  themselves. 

Who  changed  the  truth  of  God  into  a  lie,  and  worshiped  and  served 
the  creature  more  than  the  Creator,  who  is  blessed  forever.     Amen. 

For  this  cause  God  gave  them  up  unto  vile  afifections ;  for  even  their 
women  did  change  the  natural  use  into  that  which  is  against  nature;  and 
likewise  also  the  men  leaving  the  natural  use  of  the  women,  burned  in  their 
lust  one  toward  another ;  men  and  men  working  that  which  is  unseemly,  and 
receiving  in  themselves  that  recompense  of  their  error  which  was  meet. 

And  even  as  they  did  not  like  to  retain  God  in  their  knowledge,  God 
gave  them  over  to  a  reprobate  mind,  to  do  those  things  which  are  not 
convenient. 

The  Scriptural  authority  thus  quoted  may  not  add  any  par- 
ticular scientific  weight  to  the  subject  of  sexual  perversion,  but  it 
certainly  is  of  interest  as  showing  the  early  lay  recognition  of  this 
peculiar  morbid  state. 

The  precise  causes  of  sexual  perversion  are  obscure.*  Abnormal 
conditions  of  the  anterior  lobe  of  the  pituitary  body  perhaps  may 
be  a  causal  factor.  The  explanation  of  the  phenomenon  is,  in  a 
general  way,  much  more  definite.  Just  as  we  may  have .  variations 
of  physical  form  and  of  mental  attributes  in  general,  so  we  may 
have  variations  and  perversion  of  that  intangible  entity,  sexual 
affinity.  In  some  cases,  perhaps,  sexual  differentiation  has  been 
psychically  imperfect,  and  there  is  a  reversion  of  type ;  as  Kiernan 
remarks : — 

The  original  bisexuality  of  the  ancestors  of  the  race,  shown  in  the 
rudimentary  organs  of  the  male,  could  not  fail  to  occasion  functional,  if 
not  organic,  reversions  when  mental  or  physical  manifestations  were  inter- 
fered with  by  disease  or  congenital  defect.  The  inhibitions  on  excessive 
action  to  accomplish  a  given  purpose,  which  the  race  has  acquired  through 
centuries  of  evolution,  being  removed,  the  animal  in  man  springs  to  the 
surface.  Removal  of  these  inhibitions  produces,  among  other  results,  sex- 
ual perversion. 

It  has  been  asserted  by  the  type  of  observers  who  wear  leather 
goggles,  that  sexual  perversion  cannot  be  reversionary,  because  the 
lower  animals  are  free  from  it.  Any  one  who  has  intelligently 
studied  the  habits  of  dogs,  cattle,  horses,  fowls  and  other  domesti- 


*  The   possible    relation    of   defective    hormone    supply    to   sexual    perversion 
already  has  been  expatiated  upon. 

—  34  — 


SEXUAL   PERVERSION   AND   INVERSION 

cated  animals  well  knows  that  certain  manifestations  of  perversion 
are,  to  use  a  paradox,  normal  among  them.  The  author  has  noted 
typic  examples  of  perversion  among  fowls.  In  two  instances  of  a 
normal  laying  and  breeding  hen — who  possessed  masculine  secon- 
dary characteristics,  such  as  well  developed  spurs  and  the  crowing 
habit — the  female  bird  immediately  took  charge  of  the  walk  when- 
ever the  male  bird  was  removed,  and  devoted  herself  most  assidu- 
ously to  treading  the  other  hens.* 

Reasoning  back  to  cell-life,  we  see  many  variations  in  sexual 
affinity  and  the  function  of  reproduction  between  the  primal  fusion 
and  subsequent  segmentation  of  cells — the  lowest  type  of  procrea- 
tive  action — and  that  complete  and  perfect  differentiation  of  the 
sexes  which  requires  a  definite  act  of  sexual  congress  as  a  manifesta- 
tion of  the  acme  of  sexual  affinity  and  for  the  purpose  of  reproduc- 
tion. The  variations  in  the  methods  of  sexual  gratification — or,  to 
attribute  it  to  instinct,  of  perpetuating  the  species — which  are  pre- 
sented to  the  student  of  natural  history  are  numerous  and  striking. 
It  is  not  the  author's  intention,  however,  to  give  this  matter  more  than 
passing  notice.  The  method  of  sexual  gratification — i.  e.,  procrea- 
tion— of  fishes  is  a  curious  phenomenon.  It  is  difficult  to  appre- 
ciate the  sexual  gratification  involved  in  the  deposition  of  the  milt 
of  the  male  fish  upon  the  spawn  of  the  female,  yet  that  the  so- 
called  instinctive  act  of  the  male  is  unattended  by  gratification  is 
improbable.  Indeed,  it  is  an  argument  as  applicable  to  the  lower 
animals  as  to  man,  that,  were  the  act  of  procreation  divested  of  its 
pleasurable  features,  the  species  speedily  would  become  extinct ;  for 
the  act  of  procreation  per  sc  is  possessed  of  no  features  of  attrac- 
tiveness, but  of  many  that  are  repulsive  and  in  themselves  pro- 
ductive of  discomfort. 

It  is  puzzling  to  the  healthy  man  and  woman  to  understand 
how  the  practices  of  the  sexual  pervert  can  afi^ord  gratification.  If 
considered  in  the  light  of  reversion  of  type,  however,  the  subject 
is  much  less  perplexing.  That  maldevelopment,  or  arrested  develop- 
ment, of  the  sexual  organs  should  be  associated  with  sexual  per- 
version i-  not  at  all  surprising;  and  the  more  nearly  the  individual 
ap])r()ximates  tlie  t_\pe  of   fetal  development  which  exists  prior  to 


•The  author  el:il)r)rateil   the  theory  of  reversion  as  explanatory  of  sexual 
perversion  in  the  Pliiladelphia  Medical  &  Surgical  Reporter,  Sept.  7,   1SS9. 

—  35  — 


IMPOTENCE  AND   STERILITY 

the  commencement  of  sexual  differentiation,  the  more  marked  is 
the  aberrance  of  sexuaHty,  of  which  more  anon. 

There  is  one  element  in  the  study  of  sexual  perversion  that 
deserves  especial  attention.  It  is  probable  that  few  bodily  attributes 
are  more  readily  transmitted  to  posterity  than  peculiarities  of  sexual 
physiology.  The  offspring  of  the  abnormally-carnal  individual  is 
likely  to  be  possessed  of  the  same  inordinate  sexual  appetite  that 
characterizes  the  parent.  The  child  of  vice  has  within  it  in  many 
instances,  the  germ  of  vicious  impulse,  and  no  purifying  influence 
can  save  it  from  following  its  own  inherent  inclinations.  Men  and 
women  who  seek,  from  mere  satiety,  variations  of  the  normal 
method  of  sexual  gratification,  stamp  their  nervous  systems  with 
a  malign  influence  which  in  the  next  generation  may  present  itself 
as  true  sexual  perversion.  Acquired  sexual  perversion  in  one  gen- 
eration may  be  a  true  constitutional  and  irradicable  vice  in  the 
next,  and  this  independently  of  gross  physical  aberrations.  Care- 
lessness on  the  part  of  parents  is  responsible  for  some  cases  of 
acquired  sexual  perversion.  Boys  who  are  allowed  to  associate 
intimately  are  likely  to  turn  their  inventive  genius  to  account  by 
inventing  novel  means  of  sexual  stimulation,  with  the  result  of 
ever  after  diminishing  the  natural  sexual  appetite.  Any  power- 
ful impression  made  upon  the  sexual  system  at  or  near  puberty, 
when  the  sexual  apparatus  is  just  maturing  and  very  active,  al- 
though as  yet  weak  and  impressionable,  may  leave  an  imprint  in 
the  form  of  sexual  peculiarities  that  will  haunt  the  patient  through- 
out his  after-life.  Sexual  congress  at  an  early  period  often  leaves 
its  impression  in  a  similar  manner.  ]\Iany  an  individual  has  had 
reason  to  regret  the  indulgences  of  his  youth  because  of  its  moral 
effect  upon  his  after-life.  The  impression  made  upon  him  in  the 
height  of  his  youthful  sensibility  never  is  eradicated,  but  remains 
in  his  memory  as  his  ideal  of  sexual  matters,  for  there  is  a  physical 
as  well  as  a  psychic  memory.  Variations  of  early  impressions  may 
determine  sexual  perversion  rather  than  abormally-powerful  desire. 
Let  the  physician  who  has  the  confidence  of  his  patients  inquire  into 
this  matter,  and  he  will  be  surprised  at  the  result.  Only  a  short 
time  since,  one  of  the  author's  patients,  a  man  of  exceptional  intel- 
lect, volunteered  a  similar  explanation  for  his  own  excesses.  Satiety 
may  bring  in  its  train  a  deterioration  of  normal  sexual  sensibility, 
with  an  increase,  if  anything,  in  the  sexual  appetite.     As  a  result, 

—  36  — 


SEXUAL   PERVERSION   AND   INVERSION 

the  deluded  and  unfortunate  beinj:;"  seeks  for  new  and  varied  means 
of  gratification,  often  degradin,;,^  in  the  extreme.  Add  to  this  con- 
dition intemperance  or  disease,  and  the  individual  may  become  the 
lowest  type  of  sexual  pervert.  As  Ilammond  concisely  puts  it,  re- 
garding one  of  the  most  disgusting  forms  of  sexual  perversion : — 

Pederasty  is  generally  a  vice  resorted  to  by  debauchees  who  exhaust 
the  resources  of  the  normal  stimulus  of  the  sexual  act,  and  who  for  awhile 
find  in  this  new  procedure  the  pleasure  which  they  can  no  longer  obtain 
from  intercourse  with  women. 

As  shown  in  the  preceding  chapter,  even  when  the  differentia- 
tion of  sex  is  complete  from  a  gross  physical  stand-point,  the  re- 
ceptive and  generative  centers  of  sexual  sensibility  may  fail  to 
become  perfectly  differentiated.  The  result  under  such  circum- 
stances might  be,  upon  the  one  hand,  sexual  apathy,  and,  upon 
the  other,  an  approximation  to  the  female  or  male  type,  as  the  case 
may  be.  Such  a  failure  of  development  and  imperfect  differentia- 
tion of  structure  necessarily  would  be  too  occult  for  discovery  by 
any  physical  means  at  our  command.  It  is,  however,  only  too 
readily  recognizable  by  its  results. 

There  exists  in  every  great  city  so  large  a  number  of  sexual 
perverts  that  seemingly  their  depraved  tastes  have  been  commer- 
cially appreciated  by  the  demi-monde.  This  has  resulted  in  the 
formation  of  establishments  whose  principal  business  it  is  to  cater 
to  the  perverted  sexual  tastes  of  a  numerous  class  of  patrons. 
Were  the  names  and  social  positions  of  these  patrons  made  public 
in  the  case  of  most  of  our  large  cities,  society  would  be  regaled  with 
something  fully  as  disgusting,  and  coming  much  nearer  home,  than 
the  old  time  Pall  Mall  Gazette  exposures. 

The  individuals  alluded  to  undoubtedly  would  resent  the  ap- 
pellation of  "sexual  pervert ;"  but,  nevertheless,  in  many  instances 
they  present  the  disease  in  its  most  inexcusable  form :  that  from 
vicious  impulse.  Personally,  the  author  cannot  appreciate  any  dif- 
ference, from  a  moral  stand-point,  between  the  individual  who  is 
gratified  sexually  only  by  perverted  manipulations  performed  by 
the  opposite  sex  and  those  tnifortunate  mortals  whose  passions  can 
be  gratified  only  by  performing  the  active  role  in  the  same  disgust- 
ing performance.  One  is  to  be  pitied  for  his  constitutional  fault ; 
the  other  to  be  despised  for  his  deliberately-acquired  debasement. 
The  professional   prostitute   who  panders  to   the   depraved   sexual 

—  37  — 


IMPOTENCE  AND   STERILITY 

tastes  of  certain  male  specimens  of  the  genus  homo  has,  at  least, 
the  questionable  excuse  of  commercial  instinct,  and  in  some  cases 
the  more  valid  one  of  essential  sexual  perversion.  These  excuses 
the  majority  of  her  patrons  certainly  do  not  have. 

An  interesting  theory,  bearing  upon  the  question  of  sexual  per- 
version in  its  relations  to  evolutionary  reversion,  is  advanced  by 
Clevenger : — 

A  paper  on  "Researches  into  the  Life-history  of  the  Monads,"  by  W.  H. 
Dallinger,  F.R.M.S.,  and  J.  Drysdale,  M.D.,  was  read  before  the  Royal 
Microscopical  Society,  on  December  3,  1873,  wherein  fission  of  the  monad 
was  described  as  being  preceded  by  the  absorption  of  one  form  by  another. 
One  monad  would  fix  on  the  sarcode  of  another,  and  the  substance  of  the 
lesser  or  under  one  would  pass  into  the  upper  one.  In  about  two  hours  the 
merest  trace  of  the  lower  one  was  left,  and  in  four  hours  fission  and 
multiplication  of  the  larger  monad  began.  Professor  Leidy  has  asserted 
that  the  ameba  is  a  cannibal.  Michels  calls  attention  to  Dallinger  and 
Drysdale's  contribution,  and  draws  therefrom  the  inference  that  each  can- 
nibalistic act  of  the  ameba  is  a  reproductive  or  copulative  one,  if  the  term 
is   admissible. 

At  first  glance  such  a  suggestion  seems  ludicrous  enough ;  but  a  little 
consideration  will  show  that,  in  thus  fusing  two  desires,  we  still  have  to  get 
at  the  meaning  and  derivation  of  the  primary  one — desire  for  food.  The 
cannibalistic  ameba  may,  as  Dallinger's  monad  certainly  does,  impregnate 
itself  by  eating  one  of  its  own  kind,  and  we  have  innumerable  instances, 
among  algse  and  protozoa,  of  this  sexual  fusion's  appearing  very  much  Hke 
ingestion.  Crabs  have  been  seen  to  confuse  the  two  desires  by  actually 
eating  portions  of  each  other  while  copulating;  and,  in  a  recent  number  of 
the  Scientific  American,  a  writer  details  the  Mantis  religiosa  female  eating 
off  the  head  of  the  male  mantis  during  conjugation.  Some  of  the  female 
arachnidc  find  it  necessary  to  finish  the  marital  repast  by  devouring  the 
male,  who  tries  to  scamper  away  from  his  fate.  The  bitings  and  even  the 
embrace  of  the  higher  animals  appears  to  have  reference  to  this  derivation. 
It  is  a  physiologic  fact  that  association  often  transfers  an  instinct  in  an 
apparently  outrageous  manner.  With  quadrupeds  it  is  most  clearly  olfaction 
that  is  most  related  to  sexual  desire  and  its  reflexes ;  but  not  so  in  man. 
Ferrier  diligently  and  vainly  searched  the  region  of  the  temporal  lobe  near 
its  connection  with  the  olfactory  nerve  for  the  seat  of  sexuality;  but,  with 
the  diminished  importance  of  the  smelling  sense  in  man,  the  faculty  of  sight 
has  grown  to  vicariate  olfaction;  certainly  the  "lust  of  the  eyes"  is  greater 
than  that  of  other  special  sense-organs  among  bimana.* 

In  all  animal  life  multiplication  proceeds  from  growth,  and  until  a 
certain  stage  of  growth,  puberty,  is  reached,  reproduction  does  not  occur. 
The  complementary  nature  of  growth  and  reproduction  is  observable  in  the 


*The  "lust"   of  olfaction  is  stronger  than  Clevenger  seems  to  think.     Often 
it  is  dominant. 

—  38  — 


IMPOTENCE   AND    STERILITY 

large  size  attained  by  some  animals  after  castration.  Could  we  stop  the 
division  of  an  ameba,  a  comparable  increase  in  size  would  be  effected.  The 
grotesqueness  of  these  views  is  due  to  their  novelty,  not  to  their  being  un- 
justifiable. While  it  must  thus  seem  apparent  that  a  primeval  origin  for 
both  ingestive  and  sexual  desire  existed,  and  that  each  is  a  true  hunger,  the 
one  being  repressible  and  in  higher  animal  life  being  subjected  to  more 
control  than  the  other,  the  question  then  presents  itself:  What  is  hunger? 
It  requires  but  little  reflection  to  convince  us  of  its  potency  in  determining 
the  destiny  of  nations  and  individuals  and  what  a  stimulus  it  is  in  animated 
creation.  It  seems  likely  that  it  has  its  origin  in  the  atomic  affinities  of 
inanimate   nature,   a  view  monistic   enough   to   please   Haeckel   and   Tyndall. 

Spitzka,  in  commenting  on  the  foregoing,  says : — 
There  are  some  observations  made  by  alienists  which  strongly  tend 
to  confirm  Clevenger's  theory.  It  is  well  known  that,  under  pathologic 
circumstances,  relations,  obliterated  in  higher  development  and  absent  in 
health,  return  and  simulate  conditions  found  in  lower,  and  even  in  primitive, 
forms.  An  instance  of  this  is  the  pica,  or  morbid  appetite  of  pregnant 
women  and  hysteric  girls  for  chalk,  slate-pencils,  and  other  articles  of  an 
earthy  nature.  To  some  extent  this  has  been  claimed  to  constitute  a  sort  of 
reversion  to  the  oviparous  ancestry,  which,  like  the  birds  of  our  day,  sought 
the  calcareous  material  required  for  the  shell-structure  in  their  food.  There 
are  forms  of  mental  perversion  properly  classed  under  the  head  of  the 
degenerative  mental  states  in  which  a  close  relation  between  the  hunger 
appetite  and  sexual  appetite  becomes  manifest. 

Under  the  heading  "Wollnst,  Mordlust,  AntJiropophagie," 
Krafft-Ebing  describes  a  form  of  sexual  perversion  where  the  suf- 
ferer fails  to  find  gratification  unless  he  or  she  can  bite,  eat,  murder, 
or  mutilate  the  mate — sadism.  He  refers  to  the  old  Hindoo  myth, 
Civa  and  Durga,  as  showing  that  such  observations  in  the  sexual 
sphere  were  not  unknown  to  the  ancient  races.  He  gives  an  in- 
stance where,  after  the  act,  the  ravisher  butchered  his  victim  and 
would  have  eaten  a  piece  of  the  viscera ;  another  where  the  criminal 
drank  the  blood  and  ate  the  heart ;  still  another,  where  certain 
parts  of  the  body  were  cooked  and  eaten.  Nature  (London),  com- 
menting on  Kiernan's  article,  quotes  Ovid :  "MiiUeres  in  coitii 
nonnemque  genas  cervicemque  maris  mordunt." 

Illustrations  of  the  varying  types  of  sexual  perversion  are,  of 
late  years,  finding  their  way  into  literature.  A  very  interesting 
series  of  cases  of  inverted  sexuality  is  reported  by  Krafift-Ebing, 
which  vividly  demonstrate  the  psychic  ]^eculiarities  of  their  class. 
The  following  is  a  fair  type,  save  in  the  fact  that  the  condition  was 

—  39  — 


SEXUAL   PERVERSION   AND   INVERSION 

in  no  way  betrayed  by  femininity  of  physique.     This  is  not  usual, 
but  by  no  means  rare : — 

Case  1. — Mr.  X.,  merchant,  residing  at  the  time  in  America,  38  years 
old,  said  to  be  of  a  family  sound  in  mind  and  body,  affected  since  youth  with 
neurasthenic  complaints,  otherwise  sound,  wrote  me  in  the  fall  of  1882  a  long 
letter,  the  most  important  parts  of  which  are  here  transcribed : — 

"I  have  read  your  article  in  the  Zeitschrift  fur  Psychiatrie.  By  it  I  and 
thousands  of  others  are  rehabilitated  in  the  eyes  of  every  thinking  and  half- 
way-fairminded  man,  and  I  give  you  my  heartiest  thanks.  I  well  understand 
that  science  has  taken  hold  of  this  matter  so  recently  that,  in  the  eyes  of  one 
whose  mind  is  sound  and  who  is  unversed  in  the  nature  of  this  disease,  it 
appears  as  a  horrible  and  unnatural  crime.  Ulrich  has  not  overestimated 
the  prevalence  of  this  disease.  In  my  own  city  (13,000  inhabitants)  I  per- 
sonally know  of  fourteen  cases,  and  in  a  city  of  60,000  people  I  know  of 
eighty. 

"I  will  take  the  liberty  of  encroaching  on  your  time  by  giving  a  short 
sketch  of  my  life,  and  shall  do  so  with  all  frankness.  It  will  perhaps  furnish 
you  with  data  for  your  critical  studies  of  this  malady.  You  may  make  such 
use  of  these  statements  as  you  see  fit  so  long  as  my  name  is  suppressed. 

"Music  and  literature  were  always  my  hobbies.  My  whole  disposition  is 
feminine.  I  hate  all  noise,  disturbance,  and  obscenity.  As  a  child,  I  asso- 
ciated constantly  with  girls  and  played  with  their  dolls  and  toy-kitchens.  I 
liked  to  dress  in  girls'  clothes  and  so  earned  the  nickname  of  'girl-lover' 
{'mddchen-schmecker').  Afterward,  when  I  became  a  student  and  took 
part  in  turning  and  gymnastics,  it  was  still  my  delight  to  help  my  mother 
in  her  household  duties.  At  the  age  of  thirteen  I  arrived  at  puberty, — that 
is,  I  acquired  a  fondness  for  another  being;  but  it  was  for  one  of  my  own 
sex.  At  school  I  always  had  my  lover  and  was  horribly  jealous  of  any 
young  girl  or  school-mate  toward  whom  he  showed  any  preference.  My  de- 
light was  to  kiss  him,  while  ni}'  sense  of  propriety  overcame  my  sexual  de- 
sires, though  to  gratify  them  was  the  very  goal  of  my  wishes.  You  will  be 
surprised  to  learn  that  until  I  was  twenty-eight  years  of  age  I  never  had  a 
seminal  emission,  either  through  involuntary  emissions,  onanism,  or  by  per- 
forming a  perverted  sexual  act. 

"While  still  a  young  man  I  had  a  serious  love-affair  with  a  sophomore. 
He  returned  my  love  in  a  way,  but  only  with  the  enthusiastic  friendship  of 
a  boy.  Once,  when  we  happened  to  be  sleeping  together  he  naively  asked 
me  if  I  took  him  for  a  girl.  In  the  manner  of  youths  we  raved  over  poetry 
and  literature.  Our  parting  was  for  me  almost  heart-breaking.  The  young 
ladies  in  the  house  of  my  master  where  I  lived  had  no  effect  upon  me.  J 
associated  with  them  in  a  friendly,  but  entirely  dispassionate,  manner. 

"New,  but  entirely  Platonic,  love-affairs  with  young  men  followed ;  but 
although  the  outward  appearances  were  most  agreeable,  there  often  came 
over  me  the  depressing  thought — you  are  not  like  other  men — and  this 
troubled  me  most  when  I  was  in  a  circle  of  laughing,  joking  comrades  who 
were  full  of  animal  spirits  and  sometimes  indulged  in  licentious  pleasures. 

—  40  — 


IMPOTENCE  AND   STERILITY 

I  did  not  know  whether  I  should  laugh  or  cry.  It  was  an  almost  unbearable 
condition,  and  I  was  forced  constantly  to  throw  sand  in  the  eyes  of  others 
and  to  act  contrary  to  my  inclinations.  I  was  out  of  this  dilemma  only  when 
in  the  society  of  those  like  myself;  it  was  therefore  necessary  for  me  to 
seek  the  society  of  those  whom  it  would  have  been  more  advisable  for  me 
to  have  avoided.  I  never  found  in  the  society  of  beautiful  women  that  in- 
vigoration  of  the  mental  powers  which  is  commonly  the  case,  but  did  find  it 
among  fascinating  young  men.  I  prefer  to  associate  with  married  women 
or  entirely  innocent  and  ingenuous  young  ladies.  Every  attempt  to  draw 
me  into  the  matrimonial  net  disgusts  me,  and  on  the  question  of  marriage 
I  am  sensitive  to  a  ridiculous  degree. 

"Until   I  was  twenty-eight  years  old  I  had  no  suspicion  that  there  were 

others  constituted  like  myself.     One  evening  in  the  castle-garden  at  X , 

where,  as  I  subsequently  found,  those  constituted  like  myself  were  accus- 
tomed to  seek  and  find  each  other.  With  that  I  lost  my  better  manhood 
and  cainc  often  to  the  park  and  sought  similar  places  in  other  cities. 

"You  will  readily  conceive  that  with  the  knowledge  thus  acquired  there 
came  a  sort  of  comfort — the  satisfaction  of  association  and  the  sense  of  no 
longer  being  alone  and  singular.  The  oppressive  thought,  that  I  was  not  as 
others  were,  left  me.  The  love-affairs  which  now  followed  gave  my  life  a 
certain  zest  which  I  had  never  known  before.  But  I  was  only  hurrying  to 
my  fate.  I  had  formed  an  intimate  acquaintance  with  a  young  man.  He 
was  eccentric,  romantic,  and  frivolous  in  the  extreme  and  without  means. 
He  obtained  complete  control  over  me  and  held  me  as  if  I  were  his  legal 
wife.  I  was  obliged  to  take  him  into  business.  Scenes  of  jealousy  which 
are  scarcely  conceivable  took  place  in  my  house.  He  repeatedly  made  at- 
tempts at  suicide  with  poison  and  it  was  with  difficulty  that  I  saved  his 
life.  I  suffered  terribly  by  reason  of  his  jealousy,  tyranny,  obstinacy,  and 
brutality.  When  jealous  he  would  beat  me  and  threaten  to  betray  my  secret 
to  the  authorities.  I  was  kept  in  constant  suspense  lest  he  should  do  so. 
Again  and  again  I  was  obliged  to  rid  my  house  of  this  openly  insane  lover 
by  making  large  pecuniary  sacrifices.  His  passion  for  me  and  his  shameless 
avarice  drove  him  back  to  me.  I  was  often  in  utter  despair  and  yet  could 
confide  my  troubles  to  no  one.  After  he  had  cost  me  10,000  francs,  and  a 
new  attempt  at  extortion  had  failed,  he  denounced  me  to  the  police.  I  was 
arrested  and  was  promptly  condemned  to  imprisonment.  My  social 
position  was  totally  destroyed,  my  family  brought  to  sorrow  and  shame, 
and  the  friends  who  had  heretofore  held  mc  in  high  esteem  now  abandoned 
me  with  horror  and  disgust.  That  was  a  terrible  time !  And  yet  I  had  to 
say  to  myself:  'You  have  sinned — yes,  grievously  sinned — against  the  com- 
mon ideas  of  morality,  but  not  against  Nature.'  A  thousand  times  no !  A 
part  of  the  blame  at  least  should  fall  upon  the  antiquated  law  which  would 
confound  with  depraved  criminals  those  who  are  forced  by  nature  to  fol- 
low the  inclinations  of  a  diseased  and  perverted  instinct. 

"You  may  get  an  idea  of  how  natural  and  spontaneous  our  actions  are 
from  the  following  incident  :—~ 

—  41  — 


SEXUAL   PERVERSION   AND   INVERSION 

"About  two  years  ago  I  was  with  a  friend  in  a  company  of  jovial  ac- 
quaintances. A  bright,  fun-loving  young  lady  whom  I  might  well  have  a 
passion  for,  but  who,  as  a  woman,  made  no  impression  whatever  upon  me, 
dressed  herself  in  the  uniform  of  an  officer  with  moustache,  etc.  From  the 
minute  when  she  entered  the  room  in  this  metamorphosis  I  felt  sexual  pas- 
sion toward  her. 

"A  friend  once  advised  me  to  marry  and  dress  my  wife  in  male  attire. 
I  know  of  a  case  in  Geneva  where  an  admirable  attachment  between  two 
men  like  myself  has  existed  for  seven  years.  If  it  were  possible  to  have  a 
pledge  of  such  a  love  they  might  well  make  pretensions  to  marriage,  but  in 
the  absence  of  that  the  proposal  of  Ulrich  seems  laughable  indeed.  One  thing 
is  true.  Our  loves  bear  as  fair  and  noble  flowers,  incite  to  as  praiseworthy 
efforts  as  does  the  love  of  any  man  for  the  woman  of  his  affections.  There 
are  the  same  sacrifices,  the  same  joy  in  abnegation  even  to  the  laying  down 
of  life,  the  same  pain,  the  same  joy,  sorrow,  happiness,  as  with  men  of  ordi- 
nary natures. 

"I  will  add  that,  so  far  as  I  can  judge,  I  am  of  perfect  physical  build, 
and  that  there  is  nothing  remarkable  as  regards  my  sexual  organs.  My  walk 
and  voice  are  masculine,  and  one  would  never  suspect  me  to  be  what  I  have 
described,  while  many  of  my  class  betray  themselves  by  their  expression, 
downcast  eyes,  gait,  posture,  bending  of  the  body,  manner  of  sitting,  or 
dress. 

"In  consequence  of  the  disgrace  that  came  upon  me  in  my  fatherland 
I  am  obliged  to  reside  in  America.  Even  now  I  am  in  constant  anxiety 
lest  what  befell  me  at  home  should  be  discovered  here  and  thus  deprive  me 
of  the  respect  of  my  fellow-men. 

"May  the  time  soon  come  when  science  shall  educate  the  people  so  that 
they  shall  rightly  judge  our  unfortunate  class;  but  before  that  time  can 
come  there  will  be  many  victims." 

A  case  of  quite  similar  type  came  under  the  author's  observa- 
tion : 

A  man  thirty-five  years  of  age  sought  a  cure  for  sexual  inversion. 
The  subject  was  a  college  and  technical  graduate,  and  filled  the  position  of 
chief  chemist  of  a  pharmaceutical  manufacturing  concern.  He  had  noticed 
at  about  the  age  of  puberty  that  he  was  homosexually  inclined.  He  never 
had  indulged  in  perverted  practices.  Seeking  an  explanation  of  his  con- 
dition he  had  read  widely  on  the  subject  of  psychopathia  sexualis  and  had 
all  the  literature  almost  at  his  command.  He  recognized  the  psychic  ele- 
ment in  his  case  and,  endeavoring  to  cure  himself,  had  become  engaged 
to  an  estimable  young  woman.  The  engagement  lasted  for  a  year,  during 
which  time  he  never  experienced  the  slightest  normal  sexual  attraction  save 
on  one  occasion,  when  the  young  woman  in  a  frolicsome  mood  dressed  her- 
self in  her  brother's  clothes.  Subsequently  the  patient  deliberately  became 
intoxicated  and  while  in  that  condition  succeeded  in  sustaining  sexual 
relations  with  a  prostitute.  The  engagement  finally  was  broken  off  and 
the   patient  practically  had   given   up   all  hope  of   cure  until   the   idea  that 

--  42  — 


IMPOTENCE  AND   STERILITY 

hypnotism  might  succeed  suggested  itself  to  him  and  he  consulted  the 
author.  This  case  passed  from  under  observation,  and  the  subsequent  his- 
tory is  unknown  to  the  author.  A  remarkable  feature  of  the  patient's  case 
was  the  statement  that  he  was  going  to  will  his  brain  to  the  author  for 
study.  Said  he :  "I  don't  believe  you  will  find  any  pathology,  but  it  will 
do  no  harm  to  investigate." 

The  deplorable  case  of  Oscar  Wilde  was  a  pertinent  example 
of  the  association  of  perversion  with  the  highest  culture  and  a 
most  artistic  temperament. 

The  following  case  of  Krafft-Ebing's  is  an  excellent  illustra- 
tion of  inverted  sexuality  in  the  female.  It  is  a  type  that  is  quite 
familiar  to  all  students  of  the  psychology  of  sex : — 

Case  2. — Miss  X,  38  years  old,  consulted  me  in  the  fall  of  1881  regarding 
severe  spinal  irritation  and  chronic  insomnia,  for  which  she  had  extensively 
used  chloral  and  morphine. 

Her  mother  was  of  a  nervous  organization ;  the  rest  of  the  family  ap- 
parently healthy.  Her  sufferings  dated  from  a  fall  upon  the  back  received  in 
1872,  which  caused  the  patient  a  severe  shock.  In  connection  therewith 
there  developed  neurasthenic  and  hysteric  symptoms  with  severe  spinal  irri- 
tation and  insomnia.  Episodically  there  was  hysteric  paraplegia  of  eight 
months'  duration  and  instances  of  hysteric  hallucinatory  delirium  with  con- 
vulsions. In  addition  there  were  symptoms  of  morphinism.  A  stay  of 
several  months  in  the  clinic  removed  these  and  also  materially  alleviated  the 
neurasthenic  condition.  These  gratifying  results  were  in  great  part  ac- 
complished by  general   faradism. 

At  her  first  appearance  the  patient  attracted  attention  by  her  clothing, 
features,  man's  hat,  short  hair,  spectacles,  gentleman's  cravat  and  a  sort 
of  coat  of  male  cut  covering  her  woman's  dress.  She  had  coarse  male  feat- 
ures, a  rough  and  rather  deep  voice,  and  with  the  exception  of  the  bosom 
and  female  contour  of  the  pelvis,  looked  more  like  a  man  in  woman's  clothing 
than  like  a  woman.  During  all  the  time  I  had  her  under  observation  there 
were  no  signs  of  eroticism.  When  I  spoke  about  her  clothing  she  said 
she  wore  it  because  it  was  convenient. 

I  incidentally  discovered  that  as  a  child  she  had  a  fondness  for  horses 
And  masculine  pastimes,  but  never  took  any  interest  in  feminine  occupations. 
She  later  developed  a  taste  for  literature  and  sought  to  fit  herself  for  a 
teacher.  She  never  enjoyed  dancing,  and  the  ballet  had  no  interest  for  hef. 
Her  highest  enjoyment  was  to  go  to  the  circus.  Up  to  the  time  of  her 
sickness  in  1872  she  had  no  particular  fondness  for  persons  of  either  sex. 
After  this  there  developed  in  her  an  attachment  toward  women,  especially 
young  women.  She  was  never  passionately  aroused  in  her  intimacy  with 
them,  but  her  friendship  and  self-sacrifices  toward  those  she  loved  were 
boundless,  while  from  that  time  on  she  had  abhorrence  for  men  and  male 
society.  Her  relatives  informed  me  that  the  patient  had  an  offer  of  mar- 
riage in  1872,  but  refused  it.     She  took  a  trip  to  a  watering-place  and  re- 

,._  43  — 


SEXUAL   PERVERSION   AND   INVERSION 

turned  entirely  changed  sexually,  and  made  use  of  expressions  which  im- 
plied that  she  did  not  consider  herself  to  be  a  woman.  Since  then  she 
would  only  associate  with  women,  had  love-afifairs  with  them,  and  let  fall 
insinuations  that  she  was  a  man.  Her  passion  for  women  showed  itself 
in  tears,  fits,  jealousy,  etc.  While  she  was  at  the  baths  in  1874  a  young 
woman  fell  in  love  with  her,  thinking  she  was  a  man  in  woman's  clothing. 
When  this  young  lady  afterward  married,  Miss  X  became  very  melancholy 
and  complained  of  faithlessness.  Her  friends  noticed  that  after  her  sick- 
ness she  evinced  a  decided  preference  for  male  clothing  and  a  masculine 
appearance,  while  before  her  illness  she  had  been  in  nowise  other  than  a 
womanly  character,  at  least  as  regarded  her  sexual  feelings. 

Further  investigations  showed  that  the  patient  was  carrying  on  a  purely 
Platonic  love-afifair  with  a  young  woman  and  wrote  her  tender  love-letters. 

The  foregoing  case  is  a  type  that  is  very  frequently  met  with 
in  women.  It  is  by  no  means  necessary  that  the  female  should  be 
masculine  in  physique,  however.  In  such  relatively-mild  cases  she 
often  is  not.  Nor  is  it  necessary  that  physical  indulgence  of  a  per- 
verted character  should  occur ;  it  often  does  not  go  beyond  the 
psychic  phase.  Favoring  circumstances  will  inevitably  produce  the 
extreme  result,  however.  Parents,  sociologic  students,  physicians, 
and  educators  should  understand  this. 

The  medico-legal  importance  of  a  recognition  of  such  cases 
was  shown  by  the  Mitchell-Ward  murder  at  Memphis  some  years 
since. 

Tardieu  chronicles  the  following  interesting  points  with  re- 
gard to  one  form  of  sexual  perversion : — 

I  do  not  pretend  to  explain  that  which  is  incomprehensible,  and  thus  to 
penetrate  into  the  causes  of  pederasty.  We  can  nevertheless  ask  if  there  is 
not  something  else  in  this  vice  than  a  moral  perversion,  than  one  of  the 
forms  of  psychopathia  sexualis,  of  which  Kaan  has  traced  the  history.  Un- 
bridled debauchery,  exhausted  sensuality,  can  alone  account  for  pederastic 
habits  as  they  exist  in  married  men  and  fathers  of  families,  and  reconcile 
with  the  desire  for  women  the  existence  of  these  impulses  to  unnatural 
acts.  We  can  form  some  idea  on  the  subject  from  a  perusal  of  the  writings 
of  pederasts  containing  the  expression  of  their  depraved  passions.  Casper 
had  in  his  possession  a  journal  in  which  a  man,  member  of  an  old  family, 
had  recorded,  day  by  day,  and  for  several  years,  his  adventures,  his  pas- 
sions, and  his  feelings.  In  this  diary  he  had,  with  unexampled  cynicism, 
avowed  his  shameful  habits,  which  had  extended  through  more  than  thirty 
years,  and  which  had  succeeded  to  an  ardent  love  for  the  other  sex.  He  had 
been  initiated  into  these  new  pleasures  by  a  procuress,  and  the  descrip- 
tion which  he  gives  of  his  feelings  is  startling  in  its  intensity.  The  pen  re- 
fuses to  write  of  the  orgies  depicted  in  this  journal,  or  to  repeat  the  names 
which  he  gave  to  the  objects  of  his  love. 

—  44  — 


T.MPOTEX'CE   AXI)    STHRILITY 

I  have  had  frequent  occasion  to  read  the  correspondence  of  known 
pederasts  and  have  found  them  applying  to  each  other  under  the  forms  of  the 
most  passionate  language,  idealistic  names  which  legitimately  belong  to  the 
diction  of  the  truest  and  most  ardent  love.  But  it  is  difficult  not  to  admit 
the  existence  in  some  cases  of  a  real  pathologic  alteration  of  the  moral 
faculties.  When  we  witness  the  profound  degradation,  the  revolting  salacity 
of  the  individuals  who  seek  for  and  admit  to  their  disgusting  favors  men 
who  are  gifted  with  education  and  fortune,  we  might  well  be  tempted  to 
think  that  their  sensations  and  reason  are  altered ;  but  we  can  entertain  no 
doubt  on  the  subject  when  we  call  to  mind  facts  such  as  those  I  have  had 
related  to  me  by  a  magistrate,  who  has  displayed  both  ability  and  energy  in 
the  pursuit  of  pederasts.  One  of  these  men,  who  had  fallen  from  a  high 
position  to  one  of  the  lowest  depravity,  gathered  about  him  the  dirty  chil- 
dren of  the  streets,  knelt  before  them  and  kissed  their  feet  with  passionate 
submission  before  asking  them  to  yield  themselves  to  his  infamous  propo- 
sitions. Another  experienced  singularly  voluptuous  sensations  by  having  a 
vile  wretch  infiict  violent  kicks  on  his  gluteal  region.  What  other  idea  can 
we  entertain  of  such  horrors  than  that  those  guilty  of  them  are  actuated 
by  the  most  pitiable  and  shameful  insanity? 

Some  of  the  manifestations  of  sexual  perversion,  quoted  by 
various  authorities,  are  very  extraordinary,  and  it  is  difficult  to  as- 
sociate them  with  titillations  of  sexual  sensibility.  Perhaps  the  most 
familiar  of  these  cases  is  that  of  Sprague,  who  was  committed  in 
Brooklyn  many  years  ago  for  highway  robbery.  It  is  unnecessary 
to  present  this  case  in  detail,  but  an  outline  of  it  may  prove  inter- 
esting. Sprague  was  arrested  immediately  after  having  assaulted  a 
young  lady  by  throwing  her  down,  violently  removing  one  of  her 
shoes  and  running  away  with  it.  He  made  no  attempt  to  steal  any- 
thing else,  although  she  wore  valuable  jewelry.  When  the  trial 
came  on,  insanity  was  alleged  as  a  defence.  Numerous  witnesses, 
the  principal  of  whom  was  the  father  of  the  defendant,  a  clergy- 
man of  the  highest  respectability,  testified  to  the  erratic  conduct  of 
the  prisoner.  A  family  history  was  elicited  which  bore  most  perti- 
nently upon  Sprague's  case,  his  grandfather,  grandmother,  great- 
grandmother,  three  great-aunts,  and  a  cousin  having  been  insane. 
He  had  himself  in  his  youth  received  numerous  blows  and  falls  upon 
the  head,  and  within  a  year  from  the  last  head-injury  he  had  de- 
veloped severe  headaches,  associated  with  which  his  friends  noted 
a  bulging  of  the  eyes.  About  this  time  the  prisoner  developed  a 
fondness  for  stealing  and  hiding  the  shoes  of  females  about  the 
house,  and  it  was  found  necessary  by  his  relatives  and  the  female 
domestics  to  carefully  conceal  or  lock  up  their  shoes  to  prevent  his 

—  45  — 


SEXUAL   PERVERSION   AND   INVERSION 

abstracting  them.  Upon  investigation  it  was  discovered  that  the  act  of 
steaHng  or  handling  the  shoes  produced  in  him  sexual  gratification. 
The  so-called  "Jack  the  Clipper"  psychopaths,  who  assault 
women  apparently  for  the  purpose  of  stealing  their  hair,  in  most 
instances  are  sexual  perverts  of  the  Sprague  type. 

Wharton  some  years  ago  chronicled  a  most  peculiar  case  of  sex- 
ual perversion.  In  this  instance,  the  morbid  sexual  desire  impelled 
the  individual  to  assault  young  girls  upon  the  streets  of  Leipzig  by 
grasping  them  and  plunging  a  small  lancet  into  their  arms  above  the 
elbow.  The  fact  was  developed  after  his  arrest  that  these  peculiar 
acts  of  assault  were  accompanied  by  seminal  emissions.  This  au- 
thenic  case  gives  a  vivid  coloring  to  the  rational  hypothesis  that  the 
notorious  Whitechapel  assassin  was  a  sexual  pervert. 

Many  cases  of  sexual  perversion  manifest  themselves  only  un- 
der the  influence  of  disease  or  drunkenness.  Ovarian  irritation  and 
those  obscure  cases  of  hysteria  in  women  which  we  are  unable  to 
trace  to  a  definite  physical  cause  frequently  are  associated  with 
sexual  perversion.  The  physiologic  ( ?)  disturbance  incidental  to 
pregnancy  is,  in  certain  neurotic  patients,  productive  of  similar 
aberration.  Whether  the  influence  of  liquor  obtunds  the  moral  fac- 
ulties or  develops  an  inherent  defect  of  sexual  physiology  in  any 
given  case  is,  of  course,  difficult  to  determine.  The  author  knows 
of  an  individual  who  conducts  himself  with  perfect  propriety  when 
sober,  and  who  is  a  man  of  exceptional  intellect,  but  who,  when 
under  the  influence  of  alcohol,  is  too  low  for  consort  with  the 
human  species. 

Some  of  the  cases  of  sexual  perversion  that  have  come  under 
the  author's  observation  have  been  as  unique  as  that  of  Sprague's 
or  the  case  related  by  Wharton.  In  one  instance  a  man  who  fre- 
quented houses  of  ill  fame  found  it  impossible  to  qualify  sexually 
until  a  chicken  had  been  decapitated.  The  sight  of  the  struggling, 
bleeding  fowl  was  eminently  aphrodisiac  in  his  case.  Under  no 
other  circumstances  was  it  possible  for  him  to  secure  an  erection. 
In  another  case  the  pervert  was  in  the  habit  of  renting  a  full  set  of 
regal  robes,  crown  and  all.  These  he  would  put  upon  the  object 
of  his  attention.  Having  seated  the  woman  upon  an  improvised 
throne,  he  would  besiege  (  ?)  his  ready-made  queen  until  his  object 
was  attained.  Egomania  evidently  was  a  dominant  phase  of  the 
sexual  psychopathy  of  this  particular  case. 

-  46  - 


IMPOTENCE   AND   STERILITY 

Heredity,  on  the  one  hand,  and  acquired  disease  or  injury,  on 
the  other,  sometimes  bear  a  very  important  relation  to  sexual 
psychopathy.  A  very  interesting  case  bearing  on  both  these  etiologic 
factors  was  reported  by  Urquhart : — 

Case. — Young  man,  26  years  of  age,  of  medium  height  and  weight  and 
fairly  robust  development,  was  sentenced  to  one  year's  imprisonment  at 
hard  labor  as  a  punishment  for  immoral  practices.  The  judge  in  passing 
sentence  remarked  that  while  it  might  not  be  the  logical  course  of  treat- 
ment, it  was  the  only  thing  to  do,  for  he  was  not  legally  insane,  and  if  set 
at  liberty  would  only  go  on  with  his  vicious  practices.  The  heredity  in  this 
case  was  exceptionally  bad.  The  father  was  a  drunkard  and  roue.  He  was 
syphilitic  and  died  young.  The  mother  was  also  syphilitic — infected  by  the 
father  during  her  pregnancy.  Subject's  only  sister  was  a  prostitute,  but 
his  only  brother  was  decent  and  respectable.  When  a  small  boy,  subject 
fell  over  a  staircase,  striking  on  his  head  and  injuring  his  skull.  He  be- 
came unconscious,  with  bleeding  at  the  ears.  His  mother  noticed  there- 
after a  great  change  in  his  conduct.  At  school  he  soon  became  a  con- 
firmed masturbator,  and  showed  a  marked  amorous  preference  for  male 
children.  It  was  finally  discovered  that  it  was  unsafe  to  permit  other 
boys  to  be  in  his  company.  His  sexuality  toward  the  opposite  sex  was  per- 
verted, and  women  in  general  disgusted  him.  His  habits  toward  his  own 
sex  finally  attracted  the  attention  of  the  police,  because  of  which  he  at- 
tempted to  kill  himself.  He  was  finally  apprehended,  tried,  and  sentenced 
to  prison. 

A  peculiar  case  was  reported  to  the  Chicago  Medical  Society 
by  A.  R.  Reynolds,  of  a  man  who  had  a  love-affair  with  a  woman 
whose  right  lower  extremity  had  been  amputated  at  the  thigh,  and 
became  so  much  attached  to  her  that  he  afterward  was  impotent 
with  perfectly-formed  women,  it  being  necessary  for  him  to  secure 
females  who  had  undergone  mutilation  similar  to  that  of  his  former 
attachment  in  order  that  he  might  be  sexually  gratified. 

A  peculiar  phase  of  sexual  perversion  is  occasionally  seen 
among  masturbators,  male  and  female.  The  individuals  suffering 
from  this  have  a  peculiar  predilection  for  titillating  the  sexual  or- 
gans in  various  outlandish  fashions.  Such  patients  in  many  in- 
stances are  particularly  fond  of  introducing  foreign  bodies  of  vari- 
ous kinds  into  the  urethra  and  thus  gratifying  their  sexual  desires. 
Such  cases  occur  even  among  persons  who  have  opportunities  for 
normal  gratification.  Thus,  an  interesting  case  is  reported  by 
Poulet  of  a  married  woman,  the  mother  of  three  children,  who 
failed  to  receive  gratification  from  ordinary  intercourse,  and  prac- 
ticed masturbation  with  a  blunt  piece  of  wood  fastened  to  a  wire. 

—  47  — 


SEXUAL   PERVERSION   AND   INVERSION 

Her  unfortunate  failing  was  exposed  through  the  sHpping  of  the 
foreign  body  from  her  grasp  into  the  bladder.  Kiernan  reports 
a  somewhat  similar  case  of  an  insane  girl  who  was  admitted  into 
his  service  at  the  Cook  County  Insane  Asylum.  In  this  instance 
the  physical  appearance  of  the  sexual  organs  and  anus  led  to  a 
suspicion  of  pederasty,  which  was  confirmed  upon  investigation. 

A  case  of  the  author's  was  quite  remarkable : 

A  married  man,  40  years  of  age,  was  wont  to  insert  a  wire  ten-penny 
nail  into  the  urethra  for  masturbatory  purposes.  The  nail  slipped  from  his 
fingers  one  day,  and  disappeared  in  the  urethra.  After  some  hours  of  fruitless 
attempts  to  extract  the  foreign  body,  the  family  physician  brought  the  patient 
to  the  author.  The  nail  was  found  with  the  point  embedded  in  the  mem- 
branous urethra  and  the  head  lying  just  within  the  vesical  orifice.  The  author 
removed  it  by  perineal  section. 

There  are  several  types  of  sexual  perverts  that  infest  the 
streets,  alleys  and  public  buildings  of  our  large  cities  and  should 
receive  the  attention  of  the  police — who  are  well  aware  of  the  ex- 
istence of  such  defectives,  but  nevertheless  maintain  an  apathetic 
attitude  toward  them.  Certain  male  perverts  are  wont  to  mingle 
with  street  throngs  and  under  the  cover  of  the  crowd  ofifer  women 
physical  indignities  of  one  kind  or  another.  Crowded  elevators 
and  street  cars  are  favorite  haunts  for  such  depraved  persons.  An- 
other class,  "exhibitionists,"  is  quite  numerous.  These  degraded 
specimens  of  humanity  stealthily  expose  their  persons,  whenever 
the  conditions  of  opportunity  and  apparent  safety  from  punishment 
present  themselves.  The  police  are  thoroughly  cognizant  of  the 
existence  of  such  psychopathies,  but  do  not  trouble  themselves  with 
efforts  to  capture  them. 

Masochism, — the  opposite  of  sadism — is  one  of  the  most  pecu- 
liar manifestations  of  sexual  perversion.  In  this  psychopathy,  the 
subject  derives  sexual  gratification  through  submission  to  the  in- 
fliction of  pain,  usually  by  one  of  the  opposite  sex.  In  some  cases 
the  sex  by  which  the  pain  is  inflicted  is  a  matter  of  indifference,  as 
witness  the  "flagellants,"  who  titillated  their  genito-spinal  centers  by 
flogging  each  other. 

Necrophilism,  or  perverted  sexual  manipulation  of  the  dead 
body,  is  so  clearly  a  manifestation  of  insanity  that  it  requires  only 
mere  mention  here. 

Pornography — obscene  writing  and  drawing,  as  seen  on  fences 
and  the   walls  of   public  buildings   and   public   conveniences — is   a 

—  48  — 


IMPOTENCE  AND   STERILITY 

manifestation  of  perverted  psycho-sexuality.  Young  lads  who 
are  given  to  this  practice  do  not  come  under  this  classification,  but 
adult  offenders  invariably  do.  The  attention  of  the  police  au- 
thorities is  herewith  called  to  this  point  as  suggesting  that  adult 
pornographists  are  more  dangerous  to  the  community  than  the 
mere  fact  of  their  obscene  writings  and  pictures  would  imply. 

In  passing,  it  is  worthy  of  note  that  while  young  lads  of  well 
bred  families  often  are  given  to  pornography  in  the  belief  that  it 
indicates  "smartness,"  manliness  and  worldly  wisdom,  the  adult 
pornogra})hcr  usually  is  a  degenerate  of  low  type. 

The  physician — or  jurist — should  not  fall  into  the  error  of 
believing  that  the  victims  of  sexual  psychopathy  usually  belong 
to  the  uneducated  and  tmrefined  classes.  In  the  author's  exper- 
ience, the  reverse  is  true.  Sex  degeneracy  is  one  of  the  penalties 
exacted  by  nature  for  the  refinements  of  civilization.  When  races 
begin  to  degenerate  they  begin  at  "the  top"  and  neuro-psychic  de- 
generacies of  all  kinds — and  especially  those  of  a  sexual  type — 
increasingly  develop.  There  is  a  question  in  the  author's  mind 
as  to  whether  the  present  frightful  European  war  may  not  act  as 
a  social  alterative  in  this  direction.  War  involves  a  reversion  of 
humanity  toward  the  primitive  animal,  who  is  free  from  the  de- 
generative effects  of  "higher  civilization." 

The  most  shining  recent  example  of  the  combination  of 
artistic  and  literary  genius  with  inversion  was  Oscar  Wilde.  His 
Ballad  of  Reading  Gaol  is  one  of  the  finest  productions  of  modern 
English  literature.  Wilde  was  the  product  of  a  bad  heredity  plus 
the  evil  influence  of  certain  English  educational  institutions.  His 
sex  view-point  is  well  illustrated  by  the  following  quotation  from 
his  "confessions" : — 

"Don't  talk  to  me  of  the  other  sex.  First  of  all,  in  beauty 
there  is  no  comparison  between  a  boy  and  a  girl.  Think  of  the 
enormous,  fat  hips  which  every  sculptor  has  to  tone  down,  and 
make  lighter,  and  the  great  udder  breasts  which  the  artist  has  to 
make  small  and  round  and  firm,  and  then  picture  the  exquisite  slim 
lines  of  a  boy's  figure.  Xo  one  who  loves  beauty  can  hesitate  for 
a  moment.  The  Greeks  knew  that ;  they  had  the  sense  of  plastic 
beauty,  and  they  understood  that  there  is  no  comparison.  The  boy 
is  far  more  beautiful.  It  is  the  sex-instinct,  the  sinful  sex-instinct 
which  prevents   worshipping-  the  higher   form  of   beauty.      Height 

—  49  — 


SEXUAL   PERVERSION   AND   INVERSION 

and  length  of  limb  give  distinction ;  slightness  gives  grace ;  women 
are  squat.  The  boy's  figure  is  more  beautiful ;  the  appeal  it  makes 
far  higher,  more  spiritual." 

The  association  of  sexual  perversion  with  malformations  of  the 
sexual  organs  with  or  without  associated  close  approximation  to  the 
general  physique  of  the  opposite  sex,  male  or  female,  as  the  case 
may  be,  certainly  is  not  surprising.  The  author  has  met  with  some 
most  peculiar  instances  of  this  form  of  sexual  perversion.  The  re- 
lation of  both  physical  and  psychic  defects  of  sexual  differentiation 
to  sexual  perversion  has  been  expatiated  upon  in  the  preceding 
chapter. 

Tre;atm]<:nt. — The  treatment  of  sexual  perversion  has  in  the 
past  been  highly  unsatisfactory,  largely  from  the  fact  that  the  ab- 
normality of  sexual  instinct  is  due  to  defective  sexual  differentia- 
tion— psychic  or  organic,  or  both.  To  the  average  pervert,  his 
or  her  condition  seems  normal.  The  victim  recognizes  the  fact  that 
he  differs  from  the  usual  standard  of  sexual  normality,  but  he  is 
absolutely  incapable  of  reasoning  out  his  defect  from  any  other 
stand-point.  He  often  desires  to  be  cured  of  his  abnormal  sexuality 
— only,  however,  by  the  substitution  of  the  instinct  which  seems 
comnion  to  those  about  him.  There  is  no  innate  repugnance  to 
his  own  condition,  which  is  as  normal  to  his  own  mind  as  is  a  con- 
fusion of  colors  to  the  color-blind.  He  knows  his  abnormal  sex- 
uality only  from  study  and  comparison  of  normal  individuals.  He 
regrets  his  social  ostracism,  while  really  seeing  nothing  wrong  in  the 
condition  that  has  brought  it  about.  Taking  into  consideration  the 
congenital  character  of  most  cases,  the  difficulty  of  cure  is  self- 
evident.  Where  there  is  physically  imperfect  dift'erentiation  of  sex, 
the  case  is  absolutely  hopeless.  Perversion  from  impressions  of 
an  abnormal  psychosexual  character  made  while  the  sexual  func- 
tion is,  so  to  S]:)eak,  in  its  plastic,  formative  stage,  ])erversions  due 
to  functional  neuropathic  disturbances,  and  perversions  from  vice, 
are  often  susceptible  of  cure.  Therapeutic  suggestion  is  of  para- 
mount importance  in  most  cases.  Psychotherapy  often  is  the  key- 
note of  treatment.     As  ]\iernan  so  tersely  says: — 

Insistence  on  the  morhidity  of  (he  ])ervert  ideas,  and  prohibition  of 
sexual  literature  as  in  the  sexual  neurasthenic,  together  with  allied  psychic 
therapy  and  anaphrodisiac  methods  cannot  but  benefit.  These  patients,  like 
tlie  hysteric,  will  not  "will"  to  be  cured  while  they  are  subjects  of  sympathy. 

The  author  already  has  expressed  his  belief  that  in  his  owri 

—  SO  — 


niPOTEXCE    ,\XD    STERILITY 

method  of  sex-gland  implantation  we  have  a  therapeutic  resource — 
sex  hormone  therapy — which,  under  favorable  conditions,  may  offer 
hope  of  cure  of  sexual  perversions  and  inversion. 

It  has  long  been  the  author's  belief  that  a  large  proportion  of 
both  boys  and  girls  may  be  easily  converted  into  sexual  perverts 
by  unnatural  sexual  impressions  at  or  about  the  age  of  puberty, 
when  the  centers  of  sexual  receptivity  and  impulse  are  in  a  plastic 
state.  It  is  strange  that  physicians  did  not  discover  this  earlier. 
The  sexual  dangers  of  boarding-schools  long  ago  were  pointed  out 
by  a  French  novelist,  Adolph  Belot.  (^Vldlle.  Giraud,  Ma  Femme). 
A  word  of  warning,  therefore,  may  not  be  out  of  place.* 

To  emphasize  the  necessity  of  school  supervision  in  the  mat- 
ter of  exposure  of  children  to  evil  sex  influences,  the  author  will 
cite  three  cases  of  young  girls  who  became  enceinte  while  attending 
a  fashionable  boarding  school  for  girls,  and  two  cases  of  gonor- 
rhea occurring  in  girl  pupils  of  a  similar  institution.  Cases  of  boys 
corrupted  and  infected  in  boarding  schools  are  too  numerous  to 
mention.  In  passing,  the  author  desires  to  express  his  advocacy  of 
the  establishment  by  law  of  an  age  of  consent  for  boys.  xA.s  mat- 
ters now  stand,  the  debauchery  of  young  girls  is  a  crime,  whilst 
that  of  boys  is  taken  for  granted  and  carries  with  it  no  responsi- 
bility. The  extent  to  which  young  lads  are  inculcated  into  sexual 
immorality  by  lewd  women  is  far  greater  than  some  of  our  "lop- 
sided"' reformers  suspect. y 

A  most  striking  illustration  of  the  sex  dangers  to  which  school 
children  are  exposed  came  under  the  author's  observation.  A  self- 
confessed  sexual  pervert  asked  for  advice  in  the  matter  of  ac- 
cepting the  superintendency  of  a  certain  school  for  delinquent  boys 
which  had  been  tendered  him.  He  had  been  for  four  years  principal 
of  a  hi!^li  scliool.  The  tenor  of  the  author's  advice  to  this  particular 
psychopath  may  be  imagined.  Suffice  it  to  say  that,  at  last  accounts, 
the  teacher  of  youth  had  left  the  country  for  parts  unknown. 

For  the  insane  pervert  the  asylum  is  the  only  recourse.  In 
rare  instances  of  perversion,  castration,  oophorectomy,  and  clitori- 
dectomy  are  worth  consideration.  Sterilization  should  he  prac- 
ticed in  all  cases.    No  sexual  pervert  should  be  allowed  to  procreate. 

*  The  terrible  arraignment  of  the  English  schools  by  Frank  Harris  in  his 
Life  of  Oscar  Wilde  should  be  suggestive  to  educators. 

t  The  author  thus  far  has  vainly  endeavored  to  interest  legislators  in  this 
subject. 

—  51  — 


CHAPTER    IV. 

Satyriasis,  Sexual  Erethism  and  Nymphomania. 

Satyriasis  is  a  disease  that  occurs  in  the  male,  with  or  with- 
out insanity,  the  principal  manifestation  of  which  is  an  abnormally- 
excessive  and  unreasonable,  and  uncontrollable  sexual  desire.  It  is 
not  a  frequent  disease  as  brought  to  the  attention  of  the  physician, 
probably  because  the  opportunities  for  gratification  of  the  male 
are  relatively  numerous.  The  disease  consists  of  constant  desire, 
attended  with  vigorous,  often  painful,  erections,  which  in  some  in- 
stances no  amount  of  sexual  intercourse  will  relieve.  It  has  been 
termed  "erotic  delirium,"  and  it  may  or  may  not  be  due  to  coarse 
disease  of  the  brain.  In  the  worst  cases  the  unfortunate  individual 
may  be  the  subject  of  mania  and  delirium  of  a  violent  form.  Ac- 
ton relates  the  case  of  an  old  man,  suffering  from  satyriasis,  whose 
desire  was  so  extreme  that  he  would  masturbate  whenever  he  was 
brought  into  the  presence  of  women.  After  his  death  a  small  tumor 
was  found  in  the  pons  Varolii.  Shock  and  injuries  involving  the 
cerebellum  are  peculiarly  likely  to  be  followed  by  persistent  erec- 
tions. This  phenomenon  has  been  noticed  in  subjects  killed  by 
hanging.  Injuries  of  the  spinal  cord,  although  in  the  majority  of 
instances  inhibiting  the  sexual  function  by  producing  complete 
paralysis  of  that  portion  of  the  cord  which  seems  to  bear  an  inti- 
mate relation  to  sexual  sensibility — the  genito-spinal  center — pro- 
duce in  some  instances,  from  irritation  of  the  same  nervous  struc- 
ture, persistent  erection.  Cases  of  this  kind  are  related  by  Lalle- 
mand.  The  following  case  is  one  that  has  been  very  frequently 
quoted : — 

Case. — The  subject  was  a  soldier,  who,  climbing  over  the  walls  of  the 
garrison,  fell  upon  his  sacrum.  Following  this  injury  he  became  paraplegic 
and  suffered  with  persistent  priapism.  This  lasted  for  some  time,  and  could 
not  be  relieved  by  intercourse.  All  pleasurable  sensations  and  the  power  of 
ejaculation  were  destroyel,  although  sexual  desire  was  very  ardent.     During 

—  52  — 


SATYRIASIS 

sleep,  however,  the  unfortunate  subject  had  lascivious  dreams,  accompanied 
by  slight  sensation  and  ejaculation. 

The  causes  of  satyriasis,  as  enumerated  by  different  author- 
ities, are :  masturbation ;  disease  of  the  brain,  particularly  those  af- 
fecting the  cerebellum ;  injuries  and  diseases  of  the  spinal  cord, 
sexual  excesses,  and  the  administration  of  poisonous  doses  of  can- 
tharides.  Prolonged  continence  is  another  rare  and  dubious  cause 
to  which  satyriasis  has  been  ascribed.  Blandet  describes  a  case  of 
this  kind : — 

Case. — The  patient  was  an  earnest,  hard-working,  and  zealous  mis- 
sionary. He  was  unfortunate  in  the  possession  of  an  intensely  passionate 
nature,  although  he  had  not  gratified  himself  in  a  vicious  manner.  So  in- 
tense was  his  excitement  in  the  presence  of  women  that  it  became  necessary 
to  seclude  himself  from  them  so  far  as  possible.  This  plan  proved  a 
failure,  for  he  became  so  much  worse  that  he  suffered  from  satyriasis  in 
an  extreme  degree.  A  cure  was  finally  accomplished  by  the  normal  indul- 
gence of  his  passion. 

The  mild  form  of  excessive  sexual  activity  called  priapism  may 
be  due  to  local  irritation.  In  some  instances  irritation  will  pro- 
duce severe  priapism  without  sexual  desire.  The  author  once  had 
under  treatment  a  gentleman  who  was  suffering  in  this  manner: — 

Case. — The  patient  was  50  years  of  age,  had  been  somewhat  dissipated 
and  a  high  liver,  as  a  consequence  of  which  he  had  gout  in  an  extreme 
degree.  He  had  sufifered  for  several  years  from  vesical  irritation,  attributed 
by  him  to  stricture  of  long  standing.  The  urethra  on  examination  presented 
no  abnormality ;  the  urine  was  highly  concentrated  and  strongly  acid.  As 
soon  as  the  patient  retired  for  the  night  he  began  to  be  troubled  with 
severe  erections  that  were  so  vigorous  as  to  be  quite  painful  and  which 
persisted  during  the  entire  night.     Sexual  intercourse  gave  no  relief. 

Such  cases  can  be  attributed  only  to  sexual  hyperesthesia  inci- 
dental to  long-continued  gout  and  irritation  of  the  genito-urinary 
tract.  This  does  not  manifest  itself  during  the  day-time,  but  dur- 
ing the  night,  when,  as  is  well  known,  the  spinal  cord  is  relatively 
hyperemic  and  in  a  condition  of  increased  functional  activity.  The 
same  explanation  holds  good  here  as  in  nocturnal  emissions,  which 
will  be  discussed  later. 

In  another  case  of  the  author's,  no  cause  save  a  slight  deep 
linear  stricture  could  be  found.  Vasectomy,  perineal  section  and 
cerebro-spinal  sedatives  failed  to  more  than  temporarily  relieve 
this  case. 

vSatyriasis  of  greater  or  less  severity  not  infrequently  is  met 

—  53  — 


IMPOTENCE  AND   STERILITY 

with  in  elderly  men  suffering  from  prostatic  disease.  Such  cases 
usually  are  relieved  by  prostatectomy.  Annoying  and  perhaps 
persistent  priapism  often  is  noted  in  patients  afflicted  with  vesical 
calculus,  especially  in  young  children.  Children  sometimes  suffer 
from  frequent  and  obstinate  priapism  due  to  irritations  beneath  the 
prepuce.  Obviously,  operation  for  stone  in  the  one  class  and  cir- 
cumcision in  the  other  is  indicated.  The  author  is  a  persistent  and 
strenuous  advocate  of  routine  circumcision  in  male  children. 

Tumors  of  the  brain — notably  of  the  spinal  cord,  and  trauma- 
tisms of  the  brain  and  cord — especially  those  involving  the  genito- 
spinal  center,  may  cause  priapism  or  satyriasis.  Death  by  hang- 
ing often  is  accompanied  by  priapism  and  emission. 

Priapism  sometimes  is  severe  and  associated  with  perversions. 
Dr.  Wm.  H.  Dukeman  reports  a  highly  interesting  case  of  priapism 
in  which  there  was  no  desire  for  the  normal  sexual  act,  but  an 
almost  maniacal  desire  for  unnatural  indulgence:* 

Case. — A  tall  muscular  Englishman,  thirty-four  years  of  age.  Ap- 
pearance suggested  mental  depression.  His  features  looked  haggard,  and 
anemic.  Penis  was  found  in  a  rigid  state  of  erection,  which  had  per- 
sisted for  four  months.  This  had  occurred  at  frequent  intervals  for  years, 
lasting  for  two  or  three  months  at  a  time.  The  organ  measured  eight 
inches  in  length  on  the  dorsum,  twelve  inches  from  the  bulb,  and  seven 
inches  in  circumference ;  and  was  tattooed  in  various  designs  such  as  ser- 
pents' heads,  coats  of  arms,  anchors,  etc. 

No  history  could  be  elicited  suggesting  the  cause  of  the  trouble.  He 
would  not  permit  any  surgical  treatment.  Antispasmodics  and  anaphrodisiacs 
were  prescribed.  The  next  day  his  father,  an  officer  in  the  English  army, 
related  the  following  history:  While  stationed  at  the  Solomon  Islands  in 
the  South  Sea,  his  son  at  seven  years  of  age  was  stolen  by  the  natives  and 
was  not  recovered  until  he  was  eleven.  The  natives  used  the  boy  as  an 
idol,  and  practiced  on  him  sexual  perversion.  The  young  man  developed 
abnormal  desire,  with  frequent  and  continuous  priapism  with  intense  pain 
lasting  several  days.  His  only  relief  from  this  miserable  condition  was 
passive  perversion. 

He  was  married  at  sixteen  and  had  four  children.  During  his  mar- 
ried life  he  enjoyed  good  health  and  was  comparatively  free  from  the  at- 
tacks. After  death  of  his  wife,  about  nine  years  ago,  his  malady  returned 
with  more  violence  than  ever  and  for  nine  years  he  has  been  growing 
worse.  The  old  perverted  passion  returned  with  overwhelming  acuteness, 
and  during  these  times  he  would  develop  priapism  and  fall  into  a  hysterical 
or  trance-like  state  which  would  last  several  hours.  He  is  called  a  spiritual 
medium   of   unusual   attainments,   and   has   given   seances   in   various   places 


*  Pacific  Med.  Jour.,  Aug.,  1889. 

—  54 


SATYRIASIS 

along  the  coast.  It  was  found  that  he  could  be  hypnotized  by  placing  one 
hand  on  the  nape  of  his  neck  and  the  other  over  his  eyes.  Hypnosis  was 
induced  and  he  remained  in  this  condition  for  one  hour,  during  which  time 
the  penis  was  as  rigid  as  before.  While  in  this  state  he  would  talk  of  the 
natives  of  the  islands  where  he  was  taken  captive  and  of  their  peculiar 
habits. 

He  was  under  observation  for  six  weeks.  Various  remedies  were  tried 
with  no  benefit.  His  trance-like  attacks  grew  more  frequent,  and  he  re- 
fused further  treatment.  He  stated  that  sexual  intercourse  only  aggra- 
vated his  trouble,  his  only  relief  from  pain  being  his  old  perverted  habit. 
The  priapism  remained  as  persistent  as  ever.  No  spinal  lesion  was  discover- 
able. He  was  able  to  work.  In  conversation  he  used  intelligent  language 
but  there  was  some  aberration  of  the  mental  faculties. 

This  patient  died  of  pulmonary  tuberculosis  some  months  later. 
This  may  explain  the  obstinate  priapism. 

ExcEssivK  LiBiDixousxEss — Sexual  ErEThism. 

Excessive  sexual  desire  bordering  on  satyriasis  not  infrequently 
is  met  with  at  all  adult  ages.  Cases  observed  before  puberty  are, 
of  course,  classed  as  precocious  sexuality.  The  phenomenon  is  noted 
very  frequently  in  elderly  men,  in  whom  the  sexual  impulse  natur- 
ally should  be  expected  to  have  decreased — and  continually  to  de- 
crease. Prostatic  irritation — with  or  without  a  gouty  foundation — 
or  prostatic  enlargement  perhaps  is  the  most  frequent  obvious 
cause.  R.  W.  Taylor  reported  a  case  in  an  adult  due  to  vesical 
calculus.  Possibly  the  prostatic  congestion  and  irritation  result  in 
aberration  of  both  prostatic  and  testicular  hormones,  which  in 
turn  produces  irritation  of  the  psycho-sexual  and  genito-spinal  sex 
centers.     The  element  of  reflex  irritation  is  obvious. 

Elderly  and  middle  age  roues  frequently  present  a  character- 
istic psychic  predilection  for  very  young  females.  This  is  due  to : 
1st.  Pursuit  of  youthful  memories,  2nd.  To  the  increasing  develop- 
ment of  the  paternal  instinct  and  its  confusion  with  the  sexual  in- 
stinct, with  advancing  age.  The  only  saving  grace  on  the  part  of 
nature  often  is  the  waning  of  sexual  capacity  as  age  progresses. 
The  youth  often  begins  by  falling  in  love  with  a  woman  old  enough 
to  be  his  mother,  she  with  him  because  the  instinct  of  the  female 
is  to  "mother"  the  male.  "^Mothering"  a  poodle  or  a  cat  merely 
is  vicarious  sexuality.  There  is  an  element  of  pathos  in  it  all  and, 
in  a  general  way,  it  perhaps  serves  to  aid  in  the  maintenance  of 
«iex  psychology  equilibrium. 

—  55  — 


IMPOTENCE  AND   STERILITY 

The  element  of  novelty  is  a  most  powerful  psycho-sexual  stimu- 
lant and  explains  much  unethical  and  immoral  sex  conduct.  In 
the  author's  opinion  it  is  normal  and  a  much  more  powerful  factor 
in  sexual  phenomena  than  Darwin's  so-called  sexual  selection,  if, 
indeed,  it  does  not  controvert  it  and  tend  rather  to  support  Wal- 
lace's idea  of  hypernutrition  of  the  male  as  an  all-sufficient  ex- 
planation in  certain  species.  The  author  has  proved  by  experi- 
ments with  fowls  that,  in  them,  at  least,  brilliant  secondary  male  sex 
characteristics  have  no  bearing  on  the  attraction  of  the  male  for 
the  female.  A  number  of  hens  were  confined  in  a  yard  in  com- 
pany with  a  cock  of  brilliant  plumage.  At  the  end  of  four  weeks 
the  author  selected  the  most  outlandish  looking  young  mongrel 
cockerel  he  could  find,  denuded  him  of  all  feathers  save  those  of 
the  wings  and  tail,  so  that  he  resembled  the  fowls  hanging  in  a  meat 
market,  and  put  him  in  with  the  thoroughbreds.  The  hens  im- 
mediately deserted  the  splendid  lord  of  the  harem  and  flocked  to 
the  weird  looking  stranger,  who  kept  the  master  of  the  harem  ex- 
ceedingly busy  in  protecting  his  rights  until,  several  days  later,  the 
doughty  old  warrior  succeeded  in  cornering  and  killing  the  inter- 
loper. 

Nymphomania. 

Nymphomania  (erotomania,  furor  uterinus)  is  a  disease,  ana- 
logous to  satyriasis,  in  the  male,  occvirring  in  the  female.  It  is  char- 
acterized by  excessive  and  inordinate  sexual  desire,  and  very  often 
by  most  pronounced  lewdness  and  vulgarity  of  speech  and  action. 
In  the  severe  forms  it  is  likely  to  be  associated  with,  and  de- 
pendent upon,  other  forms  of  insanity,  with  or  without  gross  brain 
disease.  The  delusions  of  the  female  insane  frequently  are  sexual- 
izcd.  In  some  instances  the  disease  is  a  reflex  manifestation  of  ir- 
ritative afifections  of  the  sexual  apparatus.  Thus,  ovarian  and 
uterine  diseases  are  likely  to  be  associated  with  it.  Any  irritation 
of  the  external  genital  organs  in  females  of  hysteric  temperament 
may  produce  the  aflfection,  all  that  is  necessary  being  a  nervous  and 
excitable  state  of  the  nervous  system,  a  passionate  temperament,  and 
local  irritation  of  the  sensitive  sexual  apparatus.  Some  of  the 
recorded  cases  of  nymphomania  are  very  pitiful.  It  has  been  known 
to  be  associated  with  the  cerebral  disturbance  incidental  to  pul- 
monary consumption.    Thus,  a  case  has  been  recorded  of  a  woman 

—  56  — 


NYMPHOMANIA 

in  the  last  stages  of  this  disease  who  exhibited  the  most  inordinate 
sexual  desire,  and  a  short  time  before  her  death  importuned  her 
husband  to  have  intercourse  with  her.  The  association  of  hysteria 
with  this  unfortunate  psychosexual  condition  is  one  with  which 
nearly  every  gynecologist  of  experience  is  perfectly  familiar. 

Nymphomania  also  is  known  to  occur  as  a  result  of  masturba- 
tion and  sexual  excess.  In  women  of  a  highly  erethistic  tempera- 
ment it  has  developed  as  a  consequence  of  sudden  cessation  of  the 
normal  method  of  sexual  indulgence. 

Knowledge  or  experience  in  sexual  matters  is  by  no  means 
necessary  to  the  development  of  nymphomania,  for  it  has  been 
known  to  occur  in  individuals  who  had  neither  masturbated  nor  in- 
dulged in  sexual  intercourse.  Some  of  the  most  painful  cases  of  the 
disease  have  occurred  during  pregnancy.  The  principal  astonish- 
ing feature  of  such  unfortunate  cases  is  the  acquirement  of  lewd 
actions  and  expressions  on  the  part  of  women  previously  and  nat- 
urally pure-minded  and  refined.  Such  women  may  use  expres- 
sions and  indulge  in  actions  that  lead  the  physician  to  wonder  where 
they  possibly  could  have  acquired  a  knowledge  of  them. 

The  author  recently  removed  the  clitoris  and  labia  from  a 
young  girl  masturbator  fifteen  years  of  age  who  as  early  as  seven 
or  eight  years  of  age  showed  such  lasciviousness  that  she  was  ex- 
cluded from  every  school  in  which  she  was  placed.  There  was  a 
sexually  bad  heredity  on  the  maternal  side.  In  this  case  it  is  too 
early  as  yet  to  determine  the  result. 

The  gynecologist  is  compelled  to  be  on  his  guard  with  refer- 
ence to  a  not-infrequent  form  of  nymphomania,  but  one  which  is 
little  suspected  by  those  surrounding  the  patient,  in  which  the 
woman  develops  a  fondness  for  gynecologic  manipulations.  The 
subterfuges  and  devices  of  such  patients  to  induce  handling  of  the 
sexual  organs  by  the  physician  often  are  remarkable.  One  of  the 
most  freqvient  forms  of  this  malingering  is  the  pretense  of  reten- 
tion of  urine,  although  every  disease  that  they  ever  heard  of  may 
be  complained  of  by  such  patients  in  their  insane  endeavors  to 
obtain  manipulations  at  the  hands  of  the  physician. 

Howe  relates  an  interesting  case  of  this  kind  occurring  under 
his  observation  at  Bellevue  Hospital: — 

Case. — A  girl,  aged  18,  was  admitted,  supposed  to  be  suffering  from 
retention  of  urine.     She  was  thin ;  her  eyes  were  deep-set,  but  bright  and 


IMPOTENCE  AND   STERILITY 

staring,  and  were  found  filled  with  tears.  Her  statement  was  that  she 
had  passed  no  water  for  three  days;  that  she  was  subject  to  these  attacks 
and  was  treated  by  having  her  water  drawn  off.  I  introduced  the  catheter, 
and  found  only  a  few  ounces  of  urine  in  her  bladder,  not  enough,  indeed, 
to  corroborate  her  history.  The  next  morning,  as  she  had  not  urinated 
during  the  night,  I  drew  off  the  urine  again.  While  doing  so  I  noticed  by  a 
peculiar  convulsive  movement  that  she  was  under  the  influence  of  strong 
excitement.  Further  examination  showed  that  the  labia  minora,  clitoris, 
and  adjacent  parts  were  red  and  swelled  and  bathed  in  a  profuse  mucous 
secretion.  I  then  remembered  that  on  the  previous  evening  she  had  shown 
a  somewhat  similar  state  of  excitement,  and  gave  the  nurse  orders  to  watch 
her  closely  all  day.  In  the  evening  the  nurse  informed  me  that  the  patient 
kept  up  a  constant  friction  of  the  genitals  when  she  supposed  no  one  was 
watching,  and  even  when  eyes  were  on  her  she  endeavored  by  uneasy  move- 
ments in  the  bed  to  continue  the  titillation.  Knowing  then  what  I  had  to 
deal  with,  the  patient  was  given  a  sedative  and  told  that  she  must  empty 
her  bladder  without  assistance.  For  thirty-six  hours  subsequently  she  ob- 
stinately insisted  on  her  inability  to  urinate.  When  she  was  told  no 
catheter  would  be  employed  again  there  was  no  further  retention.  Soon 
after  she  left  the  hospital  I  learned  that  a  physician  friend  of  mine  was 
treating  her  for  uterine  disorder,  but,  he,  too,  soon  found  out  the  true 
nature  of  the  case,  and  advised  her  to  get  married.* 

An  appalling  number  of  cases  of  a  similar  nature  come  under 
the  physician's  observation,  both  in  hospital  experience  and  private 
practice. 

It  is  the  author's  belief  that  both  satyriasis  and  nymphomania 
primarily  are  due  to  a  defective  structure  or  disturbed  function — 
or  both — of  the  special  hormone-producing  cells  of  the  testis  and 
ovary.  The  secretion  may  be  lessened  in  quantity  or  vitiated  in 
quality.  This  aberration  of  the  hormone  may  be  disastrous  in 
several  ways,  viz:  1st.  Defective  general  development  (con- 
genital), 2.  Defective  physio-sexual  development  and  differentiation 
(congenital),  3rd.  Defective  psycho-sexual  development  and  differ- 
entiation (congenital),  4th.  Excessive  psycho-sexual  development 
and  activity  (congenital),  5th.  Hyperesthesia  of  previously  nor- 
mal psycho-sexual  and  genito-spinal  centers  (acquired).  It  is 
readily  understood  that  with  a  loss  of  equilibrium  between  general 
and  psycho-sexual  differentiation  and  development  would  be  as- 
sociated a  faulty  development  of  the  brain,  resulting  in  defective 
will  and  perversion  of  the  moral  faculties. 


•  Reversing  the«  abominable  custom  of  prescribing  virgins  for  the  cure  of 
disease  in  the  male. 

—  58  — 


XY^IPIIO^IAXIA 

Treatment  of  satyriasis  and  nymphomania  consists  chiefly  in 
the  removal  of  irritation  of  the  sexual  apparatus,  the  administra- 
tion of  anaphrodisiac  remedies,  to  be  hereafter  considered,  and  at- 
tempts to  restrain  sexual  excesses,  or  to  break  the  habit  of  mas- 
turbation, as  the  case  may  be.  Where  there  is  actual  organic  disease 
the  case  is  likely  to  be  found  to  be  incurable  in  the  majority  of 
instances,  particularly  if  the  structural  disease  involves  the  nervous 
centers.  In  women,  extirpation  of  the  ovaries  or  the  procedure  of 
Air.  Baker  Brown — clitoridectomy — sometimes  with  excision  of  the 
nym])ha?,  may  be  performed.  Howe  recommends  the  applica- 
tion of  the  actual  cautery  to  the  back  of  the  neck.  Basing  this  treat- 
ment upon  the  theory  that  the  disease  takes  its  origin  in  oversex- 
citation  of  the  nerve-fibres  of  the  cerebellum  or  some  of  the  gan- 
glia in  the  neighborhood,  he  also  suggests  blisters  and  setons  as 
answering  the  same  purpose.  Dry  cupping  to  the  nucha  also  is  ser- 
viceable. Means  to  restore  the  general  health  always  are  indi- 
cated. In  the  severe  cases  of  the  maniacal  form  of  excessive  sexual 
desire  the  asylum  usually  is  our  only  recourse,  though  castration  oc- 
casionally is  effective.  Castration,  liowever,  is  a  remedy  to  be 
suggested  with  the  greatest  caution.  There  recently  has  been  a 
tendency  to  recommend  this  operation  in  various  conditions  with- 
out duly  weighing  the  responsibility  involved. 

The  obvious  query  at  once  suggests  itself ;  "Why  does  not 
castration  or  oophorectomy  always  cure  cases  of  nymphomania  and 
satyriasis  due  to  perverted  hormone  supply?"  The  answer  is: 
Simply  because  :  a,  In  the  congenital  cases,  the  defective  or  vitiated 
hormone  supply  has  resulted  in  nutritive  disturbance  with  resultant 
vicious  development  of  neurons,  b.  In  the  acquired  cases  vicious 
nerve  and  brain  habit  have  been  established. 

It  may  be  ren.-iarked  tliat,  in  other  nervous  disturbances  primarily 
due  to  reflex  irritation — e.  t^.,  neuralgias  of  reflex  origin — removal 
of  the  cause  does  not  necessarily  result  in  cure.  Nutritional  changes 
in  the  reflexly  irritated  nerve  may  cause  a  persistence  of  symptoms. 

Satyriasis  and  nymphomania  sometimes  may  be  relieved  by 
removal  of  sources  of  the  reflex  sexual  irritation  which  has  caused 
a  perversion  of  hormone  production,  this  being,  in  the  author's 
opinion,  the  chief  determining  factor  in  such  cases. 

In  all  intractable  cases  of  sexual  psychosis  in  both  sexes  steril- 
ization should  be  practiced.    It  also  should  be  practiced  on  the  milder 

—  59  — 


IMPOTENCE  AND   STERILITY 

types  where  physical  degeneracy  is  determined  as  an  underlying 
cause.  Even  in  cases  in  the  male  in  which  the  protection  of  poster- 
ity is  not  in  question,  sterilization  is  the  logical  indication  and  va- 
sectomy may  prove  effective  by  lessening  hyperemia  and  hyperesthe- 
sia of  the  seat  of  sexual  desire  in  the  prostatic  urethra — the  collicn- 
lus  seminalis — and,  secondarily,  of  the  genito-spinal  center. 

If  the  author's  theory  of  the  causation  of  satyriasis  and  nym- 
phomania is  correct,  the  application  of  hormone  therapy  seems  log- 
ical. The  administration  of  normal  sex  hormone  may  act  bene- 
ficially by,  1st.  improving  the  nutrition  of,  and  stimulating  normal 
hormone  production  by,  the  patient's  own  glands,  2nd.  by  improv- 
ing the  nutrition  of  the  psycho-sexual  centers  and  thereby  correct- 
ing the  evil  effects  of  vitiated  hormone  action,  3rd.  by  improving 
general  nutrition  and  as  a  corollary  the  general  health,  4th.  by  im- 
proving the  nutrition  of  the  brain  and  thereby  improving  the  will 
power  and  the  receptive  capacity  for  moral  and  ethical  impres- 
sions. 

Attempts  at  hormone  medication  by  the  internal  administra- 
tion of  various  sex  gland  extracts  are  not  as  promising  as  some 
would  have  us  believe.  The  testicular  substances  in  particular  are 
disappointing.  In  the  treatment  of  the  female,  the  corpus  luteum 
substance  apparently  is  more  reliable  than  the  testicular  prepara- 
tions are  in  the  sexual  disturbances  of  the  male.  It  is  to  be  hoped 
that  experimental  organo-therapy  eventually  will  produce  more  re- 
liable preparations  than  many  of  those  at  present  in  vogue.  The 
author's  method  of  sex  gland  implantation  seemingly  at  present  is 
the  only  reliable  method  of  administering  the  hormone.  This  later 
will  receive  extended  discussion. 

It  is  claimed  by  Von  der  Kolk,  that  the  sexual  excitement 
which  sometimes  complicates  mania  is  due  to  changes  in  the 
medulla.     Here,  sedation  alone  offers  a  prospect  of  relief. 


60  — 


CHAPTER    V. 
Masturbation,  Sexual  Excess  and  Unphysiologic  Coitus. 

Masturbation'. 

^lasturbation — often  erroneously  styled  onanism — consists  in 
the  production  of  the  venereal  orgasm  by  some  mechanic  means 
other  than  normal  sexual  congress— usually  by  manual  friction.  Per- 
verted methods  of  sexual  contact  properly  come  under  a  different 
head. 

The  habit  of  masturbation  is  very  common,  especially  in  the 
male.  The  larger  proportion  of  young  lads  become  addicted  to  it, 
sooner  or  later,  to  a  greater  or  less  degree,  and  it  is  far  more  com- 
mon in  adult  life  than  is  generally  believed.  The  habit  sometimes 
persists  after  marriage,  even  where  the  individual  is  potent.  A 
number  of  cases  of  this  kind  have  come  under  the  author's  obser- 
vation. Regarding  the  prevalence  of  the  practice,  it  is  probable 
that  few  boys  escape  it ;  indeed,  competent  authorities  have  asserted 
that  the  man  who  can  truthfully  say  that  he  has  never  mastvu^bated 
is  a  rara  avis. 

Fortunately  for  the  comparative  reputation  of  the  human  species 
for  intelligence  and  decency,  masturbation  is  met  with  in  the  lower 
anin]als.  Bulls,  dogs,  cats,  monkeys  and  domestic  fowls  have  been 
known  to  practice  it.  Howe  claims  that  in  such  instances  the  animals 
have  received  pernicious  training  from  degraded  human  beings,  but 
students  of  natural  history  are  not  likely  to  agree  with  this  view. 

As  in  human  beings,  accidental  stimulation  of  the  sexual  organs 
sometimes  is  responsible  for  the  inculcation  of  the  habit  in  the  lower 
animals.  What  would  have  been  Howe's  opinion  of  the  case  of  a 
young  heifer  who  allowed  the  approach  of  the  bull  at  any  and  all 
times,  in  season  and  out  of  season?  Or  of  the  actions  of  heifers  out 
of  the  rutting  season,  who  never  have  come  in  contact  with  any  but 
their  own  sex? 

^lasturbation  is  a  vice  especially  of  civilized  humanity.  Pre- 
cocious passions,  incidental  to  an  immoral  and  sexually-exciting  en- 

—  61  — 


IMPOTENCE  AND   STERILITY 

vironment,  associated  with  a  defective  will-power  and  degenerate 
nerve-constitution  follow  in  the  wake  of  civilization.  The  restric- 
tions put  upon  sexual  indulgence  in  civilized  social  systems  are 
such  that  the  fear  of  consequences  deter  both  sexes — the  female 
especially — from  sexual  indulgence.  There  is  no  restriction  of  op- 
portunities and  no  social  penalties  for  masturbation,  hence  the 
individual  deems  himself  privileged  to  indulge  as  he  sees  fit.  The 
influences  to  which  boys  especially  are  subjected  are  of  the  worst 
sort.  Erotic  books,  pictures,  newspaper  nastiness,  vile  plays  and  the 
counsel  and  example  of  depraved  associates — often  of  adult  age — 
tend  to  keep  the  sexual  organs  in  a  perpetual  condition  of  excite- 
ment. Curiosity  often  is  a  factor  in  the  etiology  of  masturbation. 
Accidental  friction  of  the  genitals  develops  the  interesting  fact  that 
pleasurable  sensations  are  thereby  elicited.     The  result  is  obvious. 

Many  boys  are  led  into  the  habit  by  the  teachings  of  depraved 
adults  zvho  convey  the  impression  to  the  easily  influenced  mind  of 
the  susceptible  and  curious  boy  that  the  seminal  discharge,  however 
produced,  is  necessary  to  the  preservation  of  meanly  health. 

It  is  claimed  that  very  young  children — even  infants  at  the 
breast — have  been  known  to  masturbate.  In  such  cases  the  term 
masturbation  hardly  is  applicable.  Very  young  children,  precocious- 
ly developed  subjects  excepted,  do  not  experience  the  venereal  or- 
gasm and  emission,  and  mere  titillation  of  the  genitalia  cannot  fairly 
be  pronounced  masturbation.  Irritation  of  the  genitalia  often  im- 
pels children  to  rub  the  parts  in  the  endeavor  to  obtain  relief.  In 
some  instances  the  hands  are  used  and  in  others  the  thighs  are  spas- 
modically rubbed  together.  The  sensation  thereby  elicited  probably 
is  pleasurable  to  a  degree,  corresponding,  perhaps,  to  that  exper- 
ienced by  scratching  or  rubbing  areas  aiTected  by  pruritus  in  any 
location.  That  pleasurable  sensations  may  be  elicited  by  genital 
friction  when  the  parts  are  presumably  in  a  normal  condition  is 
shown  by  the  fact  that  vicious  nurses  not  infrequently  deliberately 
handle  the  genitals  for  the  purpose  of  quieting  the  crying  child. 

The  influence  of  genital  irritation  in  imj)elling  children  to 
handle  the  genitals  is  well  shown  in  vesical  calculus.  The  elongated 
prepuce  resulting  from  boys  with  vesical  calculus  tugging  at  the 
penis  in  a  vain  efi^ort  to  obtain  relief  from  reflex  penile  pain  is 
sufficiently  familiar. 

—  62  — 


MASTURBATION 

The  great  danger  of  genital  irritation  in  children  is  that  the  fric- 
tion induced  for  its  relief  may  be  continued  until  a  precocious  sexual 
sensibility  is  developed,  which  prolongs  the  habit  of  genital  titilla- 
tion  until  puberty  arrives  and  true  masturbation  supervenes.  A 
fact  not  generally  recognized  is  the  ])recocious  development  of  pub- 
erty as  a  consequence  of  the  frequent  and  long-continued  stimulation 
of  the  ])arts.  Here  there  is  a  reflex  stimulation  of  sex  hormone 
production  with  resultant  premature  sex  development. 

The  sources  of  irritation  that  serve  to  direct  the  child's  at- 
tention to  its  genitals  may  be  direct  or  reflex.  Among  the  direct 
causes  are  such  conditions  as  intertrigo,  eczema,  phimosis,  balanitis, 
and  the  contact  of  highly-acid  urine.  Phimosis,  and  the  consecjuent 
retention  of  irritating  secretions,  is  the  most  potent  and  frequent 
direct  source  of  irritation.  A  long  prepuce,  even  when  not  phimosed, 
is  also  a  fertile  source  of  trouble.  The  principal  reflex  causes  of 
genital  irritation  in  children  are  vesical  calculus  and  ascarides  recti. 

As  the  subject  approaches  puberty,  pseudo-emissions  finally 
characterize  infantile  attempts  at  masturbation.  The  discharge  at 
first  is  composed  only  of  urethral  and  prostatic  mucus  combined  with 
the  secretion  of  the  glands  of  Cowper.  This  discharge  is  attended 
by  a  more  or  less  typic  orgasm.  After  puberty  is  established — 
whetlicr  j)recociously  or  not — the  discharge  gradually  assumes  the 
properties  of  seminal  fluid — imperfectly  elaborated,  it  is  true,  yet 
containing  the  characteristic  s])ermatozoa.  If  the  habit  be  persisted 
in,  the  semen  never  is  perfectly  elaborated,  but  is  thin,  watery,  and 
contains  relatively  few  spermatozoa. 

The  prevalent  custom  of  allowing  children  to  sleep  together 
often  is  responsible  for  the  inculcation  of  vicious  habits  ;  this  is  espe- 
cially true  when  great  disparity  of  ages  exists,  for  a  precocious  or 
vicious  boy  or  girl  approaching  puberty  is  sure  to  contaminate  the 
morals  of  every  child  with  whom  he  or  she  is  brought  in  intimate 
contact.  vSexual  perversion  sometimes  is  thus  produced.  Parents 
should  he  taught  to  regard  every  intimate  attachment  of  their  ofi^- 
spring  for  other  children  as  worthy  of  distrust,  and  this  warning 
is  especially  justifiable  in  cities.  Country  children,  with  their  ex- 
cellent j)hysifiue  and  many  opportunities  for  the  diversion  of  their 
superflous  animal  spirits,  are  proportionately  less  likely  to  become 
vicious ;  then,  too,  they  are  not  likely  to  be  taught  vice  by  lewd 
persons  of  more  advanced  years. 

—  63  ~ 


IMPOTENCE  AND   STERILITY 

Primary  sexual  precocity  constitutes  a  foundation  for  many 
cases  of  masturbation.  This  sexual  precocity  may  be  due  (1)  to 
heredity  and  (2)  to  the  causes  of  local  irritation  already  men- 
tioned. Persons  of  an  extraordinarily  amative  disposition,  who  in- 
dulge excessively  in  sexual  intercourse,  are  likely  to  procreate 
children  who  are  not  only  feeble  in  physique  and  intellect,  but  pos- 
sessed of  premature  sexual  desire.  It  has  been  claimed  that  chil- 
dren of  illegitimate  parentage  are  very  likely  to  develop  sexual 
precocity.  This  probably  is  not  true  if  illegitimacy  is  not  asso- 
ciated with  a  vicious  environment.  Premature  sexual  desire  is 
sometimes  associated  with  a  precocious  development  of  the  sexual 
organs.  Mr.  South,  an  English  surgeon,  some  years  ago  reported 
a  case  of  a  child,  20  months  old,  in  whom  the  penis  was  larger 
than  the  average  adult  organ,  the  pubes  being  covered  with  hair. 
This  extraordinary  freak  was  addicted  to  masturbation.  Excessive 
pituitary  and  sex  hormone  activity  probably  explains  this  remark- 
able case. 

Female  children  may,  through  uncleanliness,  become  confirmed 
masturbators.  This  should  be  impressed  upon  the  minds  of  mothers 
whenever  the  opportunity  offers.  Filth  is  quite  likely  to  accumu- 
late about  the  female  genitals,  and  with  the  addition  of  highly  acid, 
or,  perhaps,  decomposed,  urine  may  produce  great  irritation.  Rub- 
bing the  genitals  is  natural  under  such  circumstances,  with  the  usual 
lamentable  results.  The  amount  of  titillation  necessary  to  produce 
an  orgasm  in  some  highly  erethistic  females  is  often  surprisingly 
slight.  The  author  has  met  with  several  cases  that  demonstrate 
this.  One,  a  single  woman  of  23,  had  only  to  will  that  an  orgasm 
occur,  in  order  to  perform  masturbation,  and  the  slightest  touch 
upon  the  genitals  when  she  was  sexually  excited  produced  the  de- 
sired result.  Another  subject,  a  girl  of  17,  masturbated  several  times 
a  day  by  simply  rubbing  the  thighs  together.  Still  another  young 
woman  has  an  orgasm  whenever  she  attempts  to  run  a  sewing  ma- 
chine. The  use  of  this  appliance  is  especially  likely  to  produce 
uterine  congestion  and  irritation,  with  coincident  sexual  excitement, 
as  every  competent  gynecologist  knows.  In  many  cases  of  mastur- 
bation among  women,  pelvic  disease  is  directly  responsible  for  the 
vice ;  hence  some  cases  must  be  regarded  in  a  more  than  charitable 
light. 

It  is  unf(jrtunate  that  we  have  so    few  opportunities  for  de- 

—  64  — 


AIASTURBATION 

teniiining  the  frequency  of  masturbation  among  women  and  female 
children,  for,  although  the  female  sex  is  much  less  vicious  than 
the  male,  the  vice  probably  often  is  responsible  for  nervous  and 
local  gynic  disease.  Women  resent  any  allusion  to  their  sexual  func- 
tions, and  mothers  usually  will  hate  the  physician  most  cordially 
if  he  so  much  as  suggests  the  possibility  of  their  children's  mas- 
turbating. They  usually  will  believe  what  is  said  of  other  chil- 
dren, but  as  to  their  own,  that  is  quite  a  different  matter.  A  short 
time  since  a  lady  brought  a  young  relative  to  the  author  regarding 
some  painful  trouble  with  the  sexual  organs.  The  child  was  only 
eight  years  of  age,  yet  it  was  precociously  developed,  and  hair  had 
already  appeared  upon  the  pubes  and  labia  majora.  The  ostium 
vaginje  was  dilated,  the  hymen  pouched  inward ;  the  nymphae  en- 
larger,  reddened,  and  bathed  with  mucus  and  the  clitoris  larger  than 
in  most  women.  The  slightest  touch  upon  the  parts  caused  the  clitoris 
to  become  erect,  and  the  involuntary  movements  of  the  child's 
limbs  showed  plainly  the  nature  of  the  trouble.  To  say  that  the 
mother  resented  the  diagnosis  would  be  putting  it  mildly.  Neither 
false  modesty  nor  the  fear  of  resentment  on  the  part  of  parents 
should  deter  the  physician  from  his  plain  duty  in  these  delicate  mat- 
ters. It  is  a  discouraging  fact  that  it  is  difhcult  to  impress  these 
points  upon  parents.  Whether  this  be  due  to  their  cerebral  density 
or  to  an  oversensitive  recollection  of  their  own  evil  ways  is  a  ques- 
tion difficult  to  answer. 

Young  girls — and,  upon  the  average,  adult  females — are  natur- 
ally much  purer  minded  than  the  male  sex,  and  their  associations  are 
not  likely  to  be  such  as  tend  to  lower  the  moral  tone.  Wh'en  the 
female  becomes  corrupted,  it  is  usually  through  the  efforts  of  the 
opposite  sex,  and  not  through  the  influence  of  members  of  their 
own,  although  the  corrupt  woman  is  especially  dangerous  to  her 
chaster  sisters.  There  are,  of  course,  many  exceptions  to  the  rule, 
especially  in  boarding-schools,  which  are  sources  of  especial  dan- 
ger to  both  sexes.  The  female  sexual  organs  are  less  exposed  than 
the  male,  and  in  the  performance  of  the  natural  function  of  urina- 
tion are  not  handled,  as  is  necessary  with  the  male.  Females  are 
consequently  less  likely  to  discover  accidentally  that  pleasurable 
sensations  may  be  excited  by  manipulation  of  these  organs,  and 
thus  be  led  into  masturbation.  After  the  age  of  puberty  the  female 
is  protected  from  sexual  desire  to  a  certain  extent  by  the  periodic 

—  65  — 


IMPOTENCE  AND   STERILITY 

relief  afforded  to  the  generative  apparatus  through  the  physio- 
logie  function  of  menstruation.  The  sexual  excitement  attendant 
upon  the  beginning  of  menstruation  usually  is  speedily  relieved  by 
the  normal  flow;  even  if  it  is  not,  it  is  obvious  that  manipulation  of 
the  organs  is  not  likely  to  be  practiced  at  that  time.  When  the  flow 
ceases,  spontaneous  sexual  excitement  usually  has  disappeared,  and 
does  not  again  recur  until  the  next  menstrual  epoch.  This  point 
should  be  taken  into  special  consideration.  In  the  case  of  the 
male  the  organs  are  not  only  handled  during  micturition,  but  they 
are  wont  to  obtrude  themselves  at  times  when  the  mind  is  entirely 
free  from  sexual  thoughts.  For  example,  the  distension  of  the 
bladder  with  the  urine  accumulated  during  the  night  is  likely  to 
produce  vigorous  erections  in  the  morning.  Such  erections,  although 
not  primarily  dependent  upon  sexual  excitement,  divert  the  mind 
in  the  direction  of  sexual  matters,  and  so  tempt  to  manipulation. 

In  a  general  way  it  may  be  asserted  that  girls  who  masturbate 
are  degenerates,  bearing  the  same  relation  to  normally  constituted 
girls  that  nymphomaniacs  do  to  normal  adults. 

Certain  kinds  of  gymnastic  exercise  are  productive  of  voluptu- 
ous sensations  that  may  lead  to  masturbation.     Howe  says : — 

These  exercises  are  common  in  gymnasiums  and  school-grounds.  My 
attention  was  first  called  to  this  subject  by  the  history  of  a  masturbator. 
He  entered  school  at  the  age  of  seven.  The  next  day  he  visited  the  school- 
gymnasium.  Noticing  the  swinging  pole,  he  took  hold  with  the  rest  of  the 
boys,  swinging  himself  around  the  circle  for  some  time.  In  a  few  minutes 
he  had  such  peculiar  sensations  about  the  genitals  that  he  had  to  stop  and 
rest.  Again  and  again  he  svv^ung  himself  around,  with  the  same  effect, 
the  sensations  becoming  more  positive  and  intense.  The  tingling  sensations 
finally  terminated  in  an  orgasm.  This  led  him  to  a  closer  examination  of 
his  organs  and  new  methods  of  excitement,  until  he  became  a  confirmed 
masturbator. 

ICxercises  involving  climbing,  swinging,  and  sliding  are  espe- 
cially pernicious ;  yet  healthy  boys  may  indulge  moderately  in  them 
without  evil  results.  A  robust  boy  is  not  likely  thus  to  injure  him- 
self, as  might  a  lad  of  less  animal  vigor  and  muscular  strength.  A 
cardinal  point  in  training  boys  should  be  to  avoid  perineal  strain 
and  friction  and  swinging  exercises  that  produce  vertigo  and 
heighten  cerebellar  sensibility,  until  the  muscles  generally  have  been 
well  trained,  and  then  to  indulge  in  such  exercises  with  great  mod- 
eration at  first.     Many  boys  experience  voluptuous  sensations  while 

—  66  — 


MASTURBATION 

climbint,^,  but  they  are  usually  delicate  lads.  The  author  has  known 
a  boy  to  fall  from  a  tree  and  experience  a  broken  arm  because  of 
an  orgasm  while  climbing. 

Both  young  and  old  subjects  with  ])rostatic  irritation  often  have 
an  orgasm  while  riding  horseback.  CJne  of  the  author's  patients 
cannot  ride  a  trotting  horse  on  this  account.  This  man  has  been  a 
masturbator,  and  latterly  experienced  gonorrheal  prostatitis  that  left 
the  seat  of  sexual  sensibility  very  hyperesthctic. 

!)Oys  of  studious  and  retiring  habits  are  most  likely  to  be  mas- 
turbators  and  to  suffer  severely  from  its  effects.  Sedentary  and  in- 
tellectual pursuits  foster  an  hyjjeresthctic  condition  of  general,  as 
well  as  sexual,  sensibility.  The  active,  i-obust  boy  who  indulges  in 
out-of-door  athletic  sports,  hunting  and  so  on,  has  an  outlet  for 
what  has  been  aj)tly  termed  the  "effusive  cussedness"  of  boy-nature, 
and  is  not  disposed  to  study  his  sexual  ap])aratus.  Again,  if  he  ac- 
quires the  habit,  he  breaks  it  off  sooner  by  virtue  of  his  greater  will- 
power, and  it  is  less  likely  to  do  him  ]:)ermanent  injury  than  his 
more  delicate  and  intellectual  brother.  The  "mother's  boy,"  of  all 
others,  requires  watching. 

Obviously,  the  damage  produced  by  masturbation  is  more 
marked  in  the  male  than  in  the  female.  IMuch  vitality  is  consumed 
in  the  frequently  recurring  calls  for  a  restoration  of  a  highly-elab- 
orated and  complex  secretion  like  the  semen.  In  the  female  the 
act  produces  merely  a  succession  of  nervous  shocks,  the  injury 
produced  being  modified  by  the  nervous  resistance  of  the  individual. 
A.s  the  function  of  the  female  in  thic  sexual  act  is  comparatively 
passive,  we  are  not  likely  to  be  consulted  regarding  its  eft'ects  in 
after-life.  The  author  recalls  a  case,  however,  of  a  married  woman 
who  had  been  a  masturbator,  wlio  claimed  that  she  had  never  had 
a  natural  orgasm,  the  excitement  stopping  just  short  of  culmina- 
tion. 

The  sexual  orgasm  lias  been  likened  to  an  epilc])tic  attack, 
which,  in  trutli,  it  greatly  resembles,  both  in  its  phenomena  and 
effects,  'i'he  n;cr.tal  hebetude  and  p^liysical  prostration  following  the 
discluirge  of  "pcrve-force''  characteristic  of  an  epileptic  attack  are 
well  recognized.  Tlie  sexual  orgasm  is  analogous  to  ej)ilepsy  in 
that  it  a;)i;ears  to  be  attended  by  an  expenditure  of  nerve-force, 
followed  temporaril}-  by  a  certain  degree  of  nervous  prostration 
w'l]!  disinclinc'ition  to  mental  exertion,  and  iihvsical  lassitude.     Lai- 


IMPOTENCE  AND   STERILITY 

lemand  states  the  self-evident  fact  that  in  children  and  women  the 
effects  that  in  the  adult  male  are  termed  spermatorrhea  are  not  due 
to  a  loss  of  semen,  but  to  the  impression  made  by  the  orgasm  upon 
the  nervous  system.  This  he  terms  ehranlement  nerveux  epilepti- 
forme.  This  is  similar  to  the  nervous  exhaustion  produced  by 
mental  excitement  or  convulsions,  the  latter  being  especially  marked 
in  young  susceptible  children.  Tickling  produces  a  similar  ef- 
fect. He  relates  a  case  in  which  a  fatal  result  was  produced  by  the 
effects  of  repeated  convulsive  shocks  upon  the  brain,  similar  to  those 
received  by  sensitive  subjects  from  tickling  the  soles  of  the  feet. 

The  venereal  orgasm,  therefore,  is  not  merely  local,  involving 
pleasurable  sensations  and  the  evacuation  of  the  seminal  vesicles, 
but  profoundly  affects  the  whole  nervous  system.  So  important 
is  the  relation  of  the  sexual  act  to  the  general  nervous  system  that 
it  is  only  mature  individuals  who  can  bear  even  infrequent  acts  of 
copulation  without  more  or  less  injury.  In  young  persons  all  the 
vital  powers  should  be  conserved  for  growth  and  development. 

In  some  animals  the  epileptiform  character  of  the  sexual  orgasm 
is  very  prominent.  Writers  have  called  especial  attention  to  the 
conduct  of  the  male  rabbit,  who,  after  each  act  of  copulation,  falls 
over  upon  his  side,  the  whites  of  the  eyes  being  turned  up,  and  the 
limbs  in  a  condition  of  clonic  spasm.  Similar  phenomena  occur  in 
some  other  animals,  and  are  due  to  the  eflfect  on  the  spinal  cord  of" 
the  discharge  of  nerve-force.  The  severity  of  the  impression  or 
shock  upon  the  nervous  system  in  the  case  of  the  human  subject 
has  been  aptly  illustrated  in  those  occasional  instances  of  sudden 
death  during  or  after  copulation.  Apoplexy,  paralysis,  and  fatal 
cardiac  syncope  have  been  known  to  result  in  individuals  predis- 
posed to  these  conditions,  as  a  consequence  of  the  sexual  orgasm. 
The  relation  of  hormone  perturbation  to  the  evil  effects  of  mas- 
turbation will  be  discussed  later  in  connection  with  sexual  ex- 
cess. 

The  seat  of  sexual  sensibility  has  been  a  matter  of  some  dis- 
pute. vSome  writers  claim  that  it  resides  principally  in  the  glans 
penis.  Acton,  howcvtT,  (jucstions  the  accuracy  of  this  theory,  re- 
lating a  rase  that  aiiparently  coiUradicts  it,  as  follows: — 

Some  time  apjo  I  attended  an  officer  on  his  rctiuMi  from  India  who  had 
lost  the  wliole  of  the  ti'lans  penis.  This  patient  completely  recovered  his 
health,  llie  i)arls  healed,  and  a  considcrahle  ])ortion  of  the  body  of  the  penis 


MASTURBATION 

was  left.  He  found,  to  his  surprise,  that  the  sexual  act  was  not  only  pos- 
sible, but  that  the  same  amount  of  pleasure  as  formerly  was  still  experienced. 
He  assured  me,  indeed,  that  the  sexual  act  differed  in  no  respect — so  far  as 
he  could  detect — from  what  it  had  been  before  the  mutilation. 

It  would  be  interesting  to  know  the  final  result  in  this  case  of 
Acton's.  Is  it  not  analogous  to  those  cases  in  which,  after  amputa- 
tion of  the  arm  or  leg.  the  patient  is  haunted  for  a  time  by  the 
"ghost-hand"  or  foot? 

That  sexual  sensibility  is  not  limited  to  the  glans  penis  it 
proved  by  certain  masturbators  who,  failing  to  find  gratification 
from  ordinary  manipulation,  cause  the  orgasm  by  titillating  the  ure- 
thra. In  Acton's  case  it  is  possible  that  the  patient  was  not  per- 
fectly normal  sexually  before  the  mutilation. 

It  is  probable  that  through  external  impressions  transmitted 
by  the  eye,  ear,  and  toitch,  the  sympathetic  system  assumes  a  spe- 
cial sexual  function.  It  is  incredible  that  sexual  impressions  are 
transmitted  altogether  through  the  ordinary  sensory  nerve-filaments. 
It  is  well  known  that  emotional  excitement  produces  a  profound 
impression  upon  the  sympathetic  nervous  system.  The  nervous 
filaments  of  the  sympathetic  supplied  to  the  generative  apparatus, 
and  particularly  to  the  prostatic  sinus,  are,  in  all  probability,  the 
principal  seat  of  sexual  sensibility.  It  is  possible  that  through  their 
influence  reflex  impressions  heighten  the  ordinary  sensibility  of 
the  part,  the  secretory  function  of  the  testes,  and  the  sensibility  of 
the  prostatic  sinus,  but  this  is  effected  also  through  the  sensitive 
nerves  distributed  to  the  delicate  mucous  membrane  of  the  glans 
penis.    Acton  says : 

Accumulation  of  blood  always  causes  a  gradual  augmentation  of  sensi- 
bility; but  in  this  case  the  glans  penis,  in  passing  from  a  non-erect  state 
to  complete  turgescence,  becomes  the  seat  of  a  completely  new  and  specific 
sensibility,  up  to  this  moment  dormant.  All  the  attendant  phenomena  re- 
act on  the  nervous  centers.  From  this  it  appears  that,  in  addition  to  the 
nerves  of  general  sensibility,  which  fulfill  their  functions  in  a  state  of  re- 
pose, and  also  during  erection,  although  in  a  dififerent  manner,  there  must 
be,  in  the  glans  penis,  special  nerves  of  pleasure  the  particular  state  of 
which  does  not  take  place  except  under  the  indispensable  condition  of  a  state 
of  erethism  of  the  glans.  When  this  is  over,  the  nerves  return  to  their 
inaction  and  remain  unaffected  under  all  ulterior  excitement.  They  are, 
then,  in  the  same  condition  as  the  remainder  of  the  generative  apparatus; 
their  irritability  ceases  with  the  consummation  of  the  act,  and  together 
with  this  irritabilit}^  the  venereal  appetite  ceases,  only  to  be  repeated,  with 
the  same  resultant  phenomena,   at  each   new   excitation. 

—  69  — 


IMPOTENCE  AND   STERILITY 

Symptoms  of  Masturbation. — The  alleged  characteristic  ap- 
pearance of  the  masturbator  has  been  overestimated  by  certain 
authorities,  as  well  as  by  the  quack.  In  extreme  cases,  associated 
with  other  causes  of  debility,  the  masturbator  may  have  an  unmis- 
takable appearance,  but  in  the  majority  of  cases  in  boys,  and  nearly 
always  in  girls,  there  is  nothing  to  be  learned  from  the  physiognomy. 
Of  the  exceptional  cases  that  seem  to  present  certain  peculiarities, 
the  author  recognizes  two  classes,  viz. :  ( 1 )  the  overgrown,  clown- 
ish, but  robust  lad,  with  sheepish  expression  and  heavy,  almost 
stupid  intellect;  and  (2)  the  slender,  delicate,  and  intellectual  lad  of 
refined  ways  and  sensitive  nervous  temperament.  The  first  has  in- 
evitably a  greasy  skin,  with  plentiful  acne,  but  excellent  color ;  the 
second,  a  sallow  or  pale  complexion  and  sunken  eyes,  with  heavy 
circles  about  them.  The  clownish  lad  rarely  acknowledges  his  fault, 
but  the  more  refined  lad  is  quite  likely  to  hint  at  it  involuntarily  in 
a  round-about  fashion,  especially  if  he  already  feels  the  bad  eflfects 
of  the  vicious  practice.  Unfortunately,  many  youths  will  consult 
the  doctor  on  some  trivial  pretext,  and  become  discouraged  because 
he  does  not  intuitively  detect  the  real  difficulty.  Young  lads  often 
so  express  themselves  when  finally  confronted  with  a  direct  accusa- 
tion. 

Acton  expresses  himself  on  the  efifects  of  masturbation  as 
follows : — 

The  habit  causes  the  worst  physical  consequences.  At  first  there  is 
little  urethral  irritation.  Pain  may  occur  in  making  water,  with  a  frequent 
desire  to  micturate;  the  meatus  is  frequently  red;  and  ejaculation  previously 
excited  only  by  much  friction,  now  takes  place  immediately ;  the  secretion 
is  watery,  even  slightly  sanguinolent,  and  emission  is  spasmodic.  A  sense 
of  weight  is  felt  in  the  prostate,  perineum,  or  rectum,  and  often  anomalous 
pains  in  the  testes.  Nocturnal  emissions  become  frequent,  and  easily  ex- 
cited by  erotic  dreams.  These  at  first  are  pleasurable,  but  later  the  patient 
is  only  made  aware  of  ejaculation  by  the  condition  of  his  linen.  In  other 
instances  the  semen  does  not  pass  away  in  jets,  but  flows  away  imperceptibly. 
In  some  cases  it  makes  its  way  back  into  the  bladder.  Other  patients  will 
tell  you  that  emissions  have  ceased,  but  on  going  to  stool,  with  the  last  drops 
of  urine,  a  quantity  of  viscid  fluid,  varying  from  a  drop  to  a  teaspoonful, 
dribbles  from  the  end  of  the  penis,  perhaps  containing  spermatozoa  in 
greater  or  less  number. 

The  vicious  habit — having  impaired  the  growth,  health,  and  intellect 
of  the  patient — ceases  often  to  be  voluntarily  indulged  in,  because  no  longer 
pleasurable.  The  drain  on  the  system  during  defecation  or  micturition, 
however,   continues,   and   what   depended   at   first   on   artificial  excitement,   is 

—  70  — 


MASTURBATION 

kept  lip  by  irritation  or  inHamniation  of  the  urethra,  vesicuke  seminales,  and 
spermatic  ducts.  Too  frc(iuent  irritation  of  the  testes  causes  badly-formed 
semen  to  be  secreted,  which  is  at  once  emitted.  The  mucous  membrane  is 
more  sensitive  than  usual,  acquiring  an  irritability  like  that  often  seen  in  the 
bladder,  and  which  irritability  appears  more  or  less  general.  Pleasurable 
sensations  seldom  attend  the  expulsion  of  ill-conditioned  semen,  overuse  of 
the  sensations  probably  causing  them  to  become  blunted.  The  patient  is  now 
frequently   reduced   to   complete   bodily  and   mental   impotence. 

The  majority  of  scientific  surgeons  will  hardly  accept  this  de- 
scription of  the  effects  of  masttirhation  as  applying  to  any  but  ex- 
ceptional cases.  Obviotisly,  it  often  is  difficult  to  determine  the 
precise  relation  of  certain  symptoms  to  masturbation.  While  the 
quack  from  purely  mercenary  motives  has  overdrawn  the  evils  of 
the  habit,  respectable  medical  men  have  been,  too  mtich  inclined  to 
go  to  the  other  extreme,  and  either  ignore  the  subject  entirely  or 
pass  it  by  as  a  matter  of  trivial  importance.  jNIr.  Acton  is  a  notable 
exception  to  the  rule,  but  has,  perhaps,  presented  the  subject  more 
forcibly  than  it  deserves. 

Admitting  that  serious  effects  of  masturbation  are  relatively 
rare,  its  restilts  are  none  the  less  worthy  of  attention : — 

The  first  effect  in  confirmed  cases  is  a  general  lack  of  tone  in 
the  generative  apparatus.  The  penis  and  testes  are  relaxed  and  flabby, 
and  the  scrotum  pendulous ;  varicocele  often  exists.  Great  sensi- 
tiveness of  the  urethra,  and  especially  of  the  prostatic  sinus  are 
usual,  and  this  in  many  cases  is  a  source  of  pseudo-impotence  by 
producing  premature  ejaculation.  According  to  Lallemand,  thicken- 
ing, degeneration,  and  often  atrophy  of  the  ejaculatory  dticts,  sem- 
inal vesicles,  and  seminal  tubules  sometimes  are  seen.  Such  condi- 
tions are  rare,  but  occasionally  are  to  be  observed  in  some  cases  of 
"Alasturbatory  insanity."  Prostatic  sensibility  is  generally  increased, 
and  confirmed  masturbators  are  likely  to  develop  prostatitis,  semi- 
nal vesiculitis,  cystitis,  or  epididymitis,  during  an  attack  of  gonor- 
rhea. 

The  symptoms  of  masttirhation  in  children  and  youths  are  by 
no  means  so  clear  as  some  authors  would  have  us  believe.  Thus 
Lallemand  remarks  as  follows : 

However  young  children  may  be,  they  get  thin,  pale,  and  irritable,  and 
their  features  become  haggard.  We  notice  the  sunken  eye,  the  long, 
cadaverous-looking  countenance,  the  downcast  look  which  seems  to  arise 
from  a  consciousness  in  the  boy  that  his  habits  are  suspected,  and,  at  a 
later  period,  from  the  ascertained  fact  that  his  virility  is  lost.     Habitual  mas- 

—  71  — 


IMPOTENCE   AND   STERILITY 

turbators  have  a  damp,  moist,  cold  hand,  very  characteristic  of  great  exhaus- 
tion ;  their  sleep  is  short,  and  most  complete  marasmus  comes  on ;  they  may 
gradually  waste  away  if  the  evil  passion  is  not  got  the  better  of ;  nervous 
symptoms  set  in,  such  as  spasmodic  contraction,  or  partial  or  entire  con- 
vulsive movements,  together  with  epilepsy,  eclampsia,  and  a  species  of  par- 
alysis accompanied  with  contractions  of  the  limbs. 

When  a  child  whp  has  once  shown  signs  of  a  great  memory  and  of 
considerable  intelligence,  is  found  to  evince  diflficulty  in  retaining  or  com- 
prehending what  he  is  taught,  we  may  be  sure  then  it  does  not  depend 
upon  indisposition,  as  he  states,  or  idleness,  as  is  generally  supposed.  More- 
over, the  progressive  derangement  in  his  health  and  falling  off  in  his  activity 
and  application  depend  upon  the  same  cause,  the  intellectual  functions  be- 
coming enfeebled  in  the  most  marked  manner. 

While  there  is  some  consistency  in  Lallemand's  overdrawn  ac- 
count of  the  appearance  and  physical  condition  of  the  masturbator, 
the  cases  that  it  will  fit  are  few  and  far  between.  As  a  matter  of 
fact,  in  a  great  majority  of  instances  of  masturbation  the  objective 
effects  are  not  suf^ciently  marked  to  attract  attention.  Even  in 
these  oases,  however,  a  permanent  impression  may  be  made  upon 
the  constitution  of  the  individual  by  virtue  of  which  he  is  less 
strongly  organized,  more  susceptible  to  disease,  and  less  capable  of 
entering  upon  the  battle  for  existence  than  boys  who  have  mastur- 
bated but  little,  if  at  all.  Sexual  capacity  and  enjoyment  in  after- 
life may  be  considerably  impaired  as  a  consequence  of  masturbation 
in  youth,  although  the  habit  may  have  made  no  physical  impres- 
sion sufficiently  pronounced  to  attract  attention. 

Hyperesthesia  of  the  nerves  of  sexual  sensibility,  with  relaxa- 
tion of  the  mouths  of  the  ejaculatory  ducts,  colliculitis  and  dilation 
and  hypersecretion  of  the  urethral  and  prostate  follicles  are  fre- 
quent results  of  masturbation.  It  would  seem  that  the  overstimula- 
tion and  frequent  emptying  of  the  seminal  vesicles  incidental  to  the 
vicious  habit  causes  them  to  acquire  intolerance  of  their  contents ; 
this  results  in  nocturnal  emissions  and  premature  ejaculation  dur- 
ing normal  intercourse.  These  effects,  however,  in  the  majority 
of  instances,  disappear  as  the  individual  grows  older,  if  the  habit 
be  discontinued,  although  it  is  probable  that  sexual  pleasure  in 
most  instances  is  permanently  impaired.  In  a  number  of  cases, 
far  larger  than  has  been  supposed,  chronic,  persistent  inflamma- 
tion of  the  seminal  vesicles  results,  with  incidental  sexual  derange- 
ments and  neurasthenia. 

—  72  — 


NYMPHOMANIA 

As  regards  the  prognosis  in  children,  Lallemand  remarks  as 
follows : — - 

In  respect  to  the  evil  habit  in  children,  it  is  easy  to  re-establish  the 
health,  if  we  can  prevent  the  patient's  masturbating  himself,  for  at  this 
period  the  resources  of  Nature  are  great ;  not  so,  however,  when  masturbation 
occurs  after  puberty. 

In  the  female  masturbator  enlargement  and  hypersensitiveness 
of  the  clitoris  and  labia  minora,  with  a  reddened,  hypersecreting  con- 
dition of  the  mucous  membrane,  are  usual.  So  sensitive  may  the 
parts  become  that  the  most  careful  examination  may  produce 
orgasm. 

The  mind  usually  is  disturbed  in  both  sexes,  but  more  from  a 
sense  of  shame  and  a  fear  of  possible  results  than  from  physical 
cerebral  disturbance.  The  frequent  discharge  of  nervous  force 
and  the  perturbation  of  the  quantity  and  quality  of  the  sex  hormone, 
naturally  produce  more  or  less  debility  and  nervous  irritability :  i.  e., 
neurasthenia. 

The  assertion  may  be  safely  made  that  every  man  who  has  ever 
masturbated  to  any  extent  has  forever  lost,  to  a  greater  or  less  de- 
gree, his  capacity  for  sexual  enjoyment,  and  the  same  is  true  of 
women.  ]\Iuch  of  matrimonial  unhappiness  is  due  to  this  fact,  and 
the  divorce-court  speaks  volumes  in  evidence  of  it.  Failing  to  secure 
the  anticipated  pleasure,  and  not  recognizing  the  source  of  the 
fault,  the  individual  is  likely  to  stray  into  forbidden  paths  in  quest 
of  that  which,  like  the  ignis  fatiiits,  ever  eludes  the  grasp.  Per- 
sistent local  irritation  is  a  factor  in  this. 

The  importance  of  insanity  and  imbecility  in  their  relations  to 
masturbation  has  been  greatly  exaggerated,  and  authorities  are  di- 
vided as  to  the  causal  relation  of  the  vice  to  mental  disease.  Very 
often  the  physician  confounds  the  propter  with  the  post;  indeed  it 
is  probable  that  no  healthy  boy  ever  was  made  insane  by  masturba- 
tion alone.  Given,  however,  a  feeble  frame,  unstable  cerebral  equili- 
brium, structural  disease  of  the  brain,  faulty  environment,  or  heredi- 
tary predisposition,  and  masturbation  may  prove  a  powerful  ele- 
ment in  the  determination  of  insanity  and  imbecility.  [Masturba- 
tion produced  by  actual  brain  disease  as  in  senile  dementia,  or  asso- 
ciated with  sexual  perversi(Mi  does  not  concern  us  here.  Phthisis, 
epilepsy,  cardiac  disease,  neurasthenia,  Inpochondria,  nymphomania. 
satyriasis,  etc..  arc  the  principal  remaining  disturbances  alleged  to 

—  73  — 


lAiPOTENCE  AND   STERILITY 

be  produced  by  masturbation.  The  author  holds  very  much  the 
same  position  regarding  them  as  in  relation  to  insanity,  with  the 
exception  of  functional  cardiac  disturbance,  neurasthenia,  and  hypo- 
chondria. These  conditions  may  result  from  any  cause  that  pro- 
duces a  morbid  impression  upon  the  mind  and  nervous  system,  and 
are,  therefore,  frequent  results  of  masturbation. 

With  the  premise  that  some  peculiarity  of  physical  structure, 
hereditary  or  acquired,  exists  as  a  predisposing  factor,  it  must  be 
admitted  that  masturbation  is  an  occasional  cause  of  insanity.  The 
intimate  relation  between  the  functions  of  the  central  nervous  sys- 
tem and  the  sexual  organs  is  sufficient  to  suggest  the  possibility  of 
insanity  arising  from  abuse  of  the  sexual  powers,  under  physical 
circumstances   favoring  mental  derangement. 

From  a  priori  considerations,  involving  the  immediate  effects 
of  sexual  excitement  and  indulgence  upon  the  brain  and  spinal 
cord,  we  might  naturally  expect  insanity  to  be  a  frequent  result 
of  masturbation  and  excessive  venery.  It  is  to  be  remembered, 
however,  that  there  is  a  special  provision  of  nature  for  the  re- 
storation of  nerve-force  after  sexual  indulgence.  This  protects  the 
majority  of  individu.als  who  abuse  their  sexual  apparatus  from  im- 
mediate and  serious  results  involving  the  cerebro-spinal  functions. 
Even  in  the  young  and  growing  child,  and  in  the  youth  at  the  period 
of  puberty,  the  vital  powers  are  so  active,  and  the  circumstances 
promoting  tissue-building  and  repair  of  nerve-waste  so  favorable, 
that  the  nervous  structures  are  protected  for  a  long  time.  Between 
the  sexual  acts  there  is  a  rapid  building  up,  which  prevents  im- 
mediately serious  results.  When  sexual  abuse  is  discontinued, 
whether  such  abuse  consists  in  masturbation  or  overindulgence  in 
sexual  intercourse,  recuperation  is  extraordinarily  rapid.  No  matter 
how  seriously  disturbed  the  functions  of  the  cerebro-spinal  axis 
may  appear  to  be  primarily,  the  restoration  of  function  and  power 
usually  speedily  occurs  when  the  cause  of  excitation  and  irritability 
has  been  removed,  actual  structural  change  in  the  nervous  system 
being  very  rare  in  these  cases.  When,  on  the  other  hand,  there  exists 
a  condition  of  unstable  nervous  equilibrium  incidental  to  faulty  and 
imperfect  nervous  structure,  whether  due  to  heredity,  congenital 
defect,  or  arquired  disease,  the  conditions  are  entirely  different. 
I'ndcr  these  circumstances,  actual  structural  alteration  of  nerve- 
]ii)^'rs  aiKJ  cells  and  the  vessels  of  the  brain,  with  coincidental  psycho- 

—  74  — 


MASTURBATION 

pathic  phenomena,  are  naturally  to  be  expected  as  occasional  re- 
sults of  the  severe  and  repeated  shocks  to  the  susceptible  nervous 
system  produced  by  the  sexual  orgasm.  The  immediate  effect  of 
sexual  desire  upon  the  brain — even  in  individuals  considered  per- 
fectly sound  from  both  a  physical  and  mental  stand-point — is  some- 
times very  marked.  In  certain  individuals,  in  whom  the  amorous 
propensity  is  very  pronounced,  the  reason,  will,  and,  indeed,  all  of 
the  hii^her  faculties  of  the  mind  are  inhibited  for  the  time  being  un- 
der the  influence  of  sexual  passion,  leaving  the  individual  to  be 
swayed  entirely  by  his  animal  impulses.  While  in  this  condition  of 
furor  sexiialis  the  most  extravagant  and  unreasonable  acts  of  sexual 
immorality  and  crime  often  are  committed  by  individuals  who,  in 
their  sober  senses,  would  abhor  such  viciousness.  It  is  safe  to  as- 
sume that  very  few  individuals  of  a  passionate  disposition  can  be 
said  to  be  perfectly  balanced  mentally  when  under  the  influence 
of  powerful  sexual  desire.  If,  then,  the  sexual  passion  is  capable 
of  obtunding  the  moral  sensibility,  reason,  and  judgment  of  in- 
dividuals who  are  structurally  sound,  what  is  to  be  expected  of 
persons  of  a  primarily  feeble  intellect  and  faulty  nervous  structure? 
There  seems  to  exist  in  some  cases,  in  which  the  intellect  is  com- 
paratively feeble,  a  surprising  degree  of  sexuality.  As  expressed 
by  Deslands,  "the  generative  sensibility  is  often  augmented  in  pro- 
portion as  the  intellect  becomes  enfeebled." 

It  is  unfortunate  that  those  who  have  had  most  opportunities 
for  the  study  of  masturbatory  lunatics  have  not  made  a  more  care- 
ful analysis,  not  only  of  the  relation  of  masturbation  to  the  deplor- 
able mental  condition  of  their  patients,  but  of  the  relation  of  heredi- 
tary and  acquired  predisposing  causes,  to  both  the  acquirement  of 
the  habit  and  its  results  upon  the  brain. 

Some  very  eminent  writers  tend  to  exaggerate  the  importance 
of  the  relation  of  masturbation  to  insanity.  Esquirol  has  made 
much  of  the  habit  as  the  primary  cause  of  mental  maladies.  Ritchie 
says : — 

As  might  be  expected,  these  cases  chiefly  occur  in  members  of  families 
of  strict  religious  education.  Experience  supports  this  expectation;  and 
facts  also  show  that  those  who  from  this  cause  become  insane  have  gener- 
ally been  of  strictly  inoral  life,  and  recognized  as  persons  who  have  paid 
much  attention  to  the  forms  of  religion.  It  is  also  frequently  observed, 
especially  in  the  acute  attack  resulting  from  this  cause,  that  religion  forms 
a  noted  subject  of  conversation  or  delusion. 

—  75  -- 


IMPOTENCE  AND   STERILITY 

This  opinion,  so  far  as  it  goes,  really  is  a  substantiation  of  what 
already  has  been  said  regarding  the  necessity  of  some  primary  pre- 
disposing condition  in  the  majority  of  cases  of  so-called  masturba- 
tory  insanity.  It  is  hardly  conceivable  that  religion  per  se  ever  is 
a  cause  of  mental  disease.  That  prolonged  fasting  and  other  re- 
ligious exercises,  in  combination  with  the  various  emotions  to  which 
religious  ceremonies  are  prone  to  give  rise,  may  produce  mental  dis- 
turbance in  certain  individuals  of  primarily  feeble  nervous  struc- 
ture and  unstable  nervous  equilibrium  is  unquestionable. 

It  hardly  can  be  said  that  the  masturbatory  lunatic  presents  a 
characteristic  form  of  psychopathia.  Such  patients,  however,  in 
some  instances  develop  transitory  maniacal  excitement,  alternat- 
ing with  periods  of  depression  and  melancholic  delusion.  In  many 
cases  there  is  a  tendency  to  monomania  of  a  religious  cast.  In 
occasional  cases  the  melancholia  terminates  in  attempts  at  suicide 
or  self-mutilation. 

It  is  ])robable  that  epilepsy  bears  about  the  same  relation  to 
masturbation  as  does  insanity,  in  that  a  primary  predisposition  is 
necessary  in  order  that  the  cause  may  be  operative  in  its  produc- 
tion. That  individuals  subject  to  epilepsy  are  likely  to  have  an  at- 
tack when  under  the  influence  of  sexual  excitement  is  well  known. 
It  is  related  of  the  first  Napoleon — who,  as  is  well  known,  was  sub- 
ject to  epilepsy — that  he  experienced  a  paroxysm  every  time  he  at- 
tempted copulation. 

Phthisis,  as  a  result  of  masturbation  and  sexual  excess,  has 
been  dwelt  upon  mainly  by  quacks,  but  to  a  certain  extent  the  sub- 
ject has  received  attention  from  reputable  and  scientific  physicians. 
The  causal  relation  of  sexual  abuse  and  excess  to  tuberculosis  has 
been  overrated.  Instead  of  tuberculosis  being  a  frequent  result  of 
masturbation,  it  is  probable  that  the  peculiar  nervous  organization 
of  the  phthisically-disposed  very  often  is  a  predisposing  cause  of 
sexual  excess  and  masturbation.  Satyriasis  and  nymphomania  oc- 
casionally are  observed  as  phenomena  in  the  clinical  history  of 
j)hthisis.  A  case  already  has  been  mentioned  of  a  woman  in  the 
last  stages  of  consumption  who  continually  im|)ortuned  her  hus- 
band to  have  intercourse  with  her,  the  sexual  impulse  being  par- 
ticularly strong  a  short  time  before  death.  In  a  general  way,  it 
may  be  acce])tcd  that  the  relation  of  masturbation  and  sexual  excess 
to  pulmonary  consumption  is  precisely  the  same  as  that  of  any  other 

—  76  — 


MASTURBATION 

condition  involving  nervous  waste  and  vital  depression.  Anything 
that  will  lower  resisting  power  predisposes  to  phthisis.  The  fact 
that  quite  a  proportion  of  consumptive  males  are  masturbators  is 
a  very  weak  argument,  for  the  reason  that  the  majority  of  males 
masturbate  more  or  less  at  some  period  of  their  lives. 

That  sexual  excess  often  is  due  to  constimption  is  questionable. 
As  a  rule,  phthisis,  like  all  debilitating  diseases,  lessens  both  sexual 
desire  and  power. 

The  efifects  of  masturbation  and  sexual  excess  upon  the  heart 
are  very  similar  to  those  produced  by  mental  excitement,  overstudy, 
nervous  shock,  liquor,  and  the  excessive  use  of  tobacco.  Palpita- 
tion and  breathlessness  are  the  most  frequent  manifestations  of  sex- 
ual errors.  It  has  been  alleged  that  cardiac  hypertrophy  and  dilation 
may  result  from  overuse  of  the  sexual  apparatus.  This,  however, 
is  open  to  question ;  the  capacity  for  experiencing  the  orgasm  prob- 
ably becomes  exhausted  long  before  such  results  can  occur. 

Some  writers,  following  Lallemand,  have  dwelt  much  upon  a 
cold,  clammy  feel  of  the  palms  as  characteristic  of  the  masturba- 
tor,  but  this  sign  is  fallacious.  Its  only  claim  to  accuracy  probably 
lies  in  the  fact  that,  inasmuch  as  most  boys  masturbate,  it  is  safe  to 
assume  that  the  boy  with  the  moist  and  clammy  hand-clasp  is  ad- 
dicted to  the  practice  like  his  fellows.  That  the  assumption  is  likely 
to  prove  correct  in  the  majority  of  cases  is  no  proof  of  the  ac- 
curacy of  the  sign.  It  would  be  as  logical  to  assume  that  a  boy 
masturbates  because,  forsooth,  he  is  a  boy — a  very  safe  rule,  by 
the  way. 

The  peculiar  mentality  of  some  adult  masturbators  is  well  il- 
lustrated by  the  confessions  of  Rousseau.  This  unfortunate  in- 
dividual, although  one  of  the  most  renowned  litterateurs  and  philoso- 
phers of  his  day,  not  only  tacitly  confesses  in  his  writings  that  he 
habitually  practiced  masturbation,  but  delineates  in  a  most  impres- 
sive and  striking  manner  the  influences  that  contributed  to  the 
excitation  of  his  sexual  passions,  and  shows  in  an  all  too  vivid 
manner  the  attractiveness  that  the  imagination  of  youth  finds  in 
the  disgusting  habit.  In  the  words  of  an  eminent  writer  upon  the 
subject: — 

Rousseau  seemed  to  be  utterly  unaware  that  the  miserable  mental  and 
bodily  condition,  which  he  goes  on  to  describe  and  to  deplore,  was  in  any 
way  the  natural  consequence  of  the  habit.     This,  perhaps,  is  not  to  be  won- 

—  77  — 


IMPOTENCE  AND   STERILITY 

dered  at,  since  the  very  medical  men  he  consulted  did  not  attribute  his  ma- 
ladies to  the  real  cause.  Modern  experience,  however,  and  the  confessions 
of  recent  patients  who  have  sinned  and  suffered — as  Rousseau  did — give 
only  too  clear  an  explanation  of  his  ailments. 

In  the  case  of  Rousseau  the  habit  of  masturbation  undoubtedly 
was  due  primarily  to  sexual  precocity.  His  description  of  his  mental 
condition  is  most  masterly. 

The  intellectual  brilliancy  displayed  by  this  celebrated  victim 
of  masturbation  certainly  is  paradoxic,  if  the  elaborate  descriptions 
given  by  some  writers  of  the  mental  hebetude  and  stupidity  result- 
ing from  the  vice  are  to  be  believed.  The  explanation,  however, 
probably  lies  in  the  fact  that  Rosseau,  being  a  man  of  extraordinary 
sex  development  and  intellectual  power,  was  not  affected  as  the 
average  individual  would  be.  The  mental  vagaries,  inaptitude  for 
mental  concentration,  sluggishness  of  thought,  shrinking  from  so- 
ciety, hypersensitiveness,  disturbed  emotional  equilibrium,  and  mor- 
bid introspection  described  by  him  are  matters  of  every-day  ex- 
perience to  individuals  who  have  indulged  in  masturbation  to  any 
great  extent.  These  are,  moreover,  phenomena  which,  if  the  truth 
were  known,  have  been  experienced  even  by  those  who  have  suc- 
ceeded in  breaking  off  the  habit,  and  apparently  have  suffered  no 
permanent  evil  results  from  it. 

se;xuaIv  excess. 

Any  form  of  sexual  indulgence,  however  infrequently  indulged, 
is  fairly  to  be  classed  as  an  abuse  of  the  function  of  procreation  in 
subjects  who  are  not  yet  fully  matured.  Conformity  with  natural 
law  would  seem  to  demand  that  all  organisms  shall  have  arrived 
at  full  bodily  development  before  undertaking  the  most  important 
function  of  organic  life — the  perpetuation  of  the  species. 

Very  early  marriage,  as  physicians  know,  often  is  fraught  with 
danger  to  both  parents  and  offspring.  If  only  one  parent  is  over- 
young,  the  infltience  of  the  parent  who  is  fully  matured  may,  how- 
ever, counteract  the  influence  of  the  other.  The  children  of  such 
marriages  may  be  healthy,  sound  and  well  developed.  When  both 
parents  are  over-yotmg,  however,  disaster  to  the  offspring  is  almost 
inevitable.  In  either  case  the  result  to  the  immature  parent  him- 
self can  only  be  harmful. 

-  78  — 


SEXUAL   EXCESS 

YoutJis  and  xaiouj  lads,  hozccvcr,  should  be  tauijJii  to  under- 
stand that  sexual  indulgenceof  any  kind — unnatural,  illicit  or  con- 
ventional— before  the  period  of  full  maturity  is  injurious,  and  that 
the  price  of  sound  sexual  health  and  a  good  physique  in  later  life 
is  sexual  continence  during  boyhood  and  youth.  Continence,  per  se, 
probably  never  is  harmful.  The  non-elimination  of  the  seminal 
secretion  from  the  testes  often  is  prodvictive  of  great  bodily  and 
mental  vigor.  The  old  notion  that  reabsorption  of  secretion  occurs 
is  hardly  tenable,  but  lack  of  eVunination  is  attended  by  retention 
within  the  organism  of  the  elements  zvhich  go  to  make  up  the  secre- 
tion. This,  with  conservation  of  nervous  energy,  is  accountable 
for  the  tonic  and  reconstructive  effect  of  sexual  continence  where 
other  conditions  are  normal. 

The  so-called  "iriternal  secretion"  of  the  testes,  doubtless  is  in- 
dependent of  the  seminal  secretion.  It  enters  into  consideration 
here,  because  of  the  fact  that  early  abuse  of  the  sexual  function 
produces  defective  development,  thus  lessening  the  quantity  and 
perverting  the  quality  of  the  internal  secretion.  Fertility  depends, 
not  only  on  the  quantity  and  quality  of  the  seminal  secretion,  but 
also  on  the  integrity  of  the  hormone  of  the  internal  secretion. 
Virility  depends  mainly  on  the  quantity  and  quality  of  the  internal 
sex  secretion  hormone  which  enters  the  blood.  Take  away  or  per- 
vert this  secretion  and  the  principal  physical  and  mental  attributes 
of  manhood  are  lost  to  a  greater  or  less  degree.  Great  vigor  of 
mind  and  body  do  not  usually  accompany  poorly  developed  testes, 
although,  so  long  as  even  a  small  part  of  a  single  testicle  performs 
its  function,  the  subject  is  benefited  more  or  less  by  the  internal 
testicular  secretion  and  may  be  virile — possibly  even  fertile. 

Whatever  be  the  explanation,  continence,  during  the  period 
of  growth,  is  favorable  to  normal  development  and  the  highest  de- 
gree of  bodily  and  mental  vigor.  After  physical  development  is 
complete,  the  rational  performance  of  the  sexual  function  in  the 
marital  state  is  natural,  and  compatible  with  the  best  possible  physi- 
cal and  mental  condition.  Normal  performance  of  the  function 
stimulates  the  secretion  of  sex  hormone  in  both  sexes  and  its  ab- 
sorption into  the  blood. 

Stock  breeders  long  ago  learned  the  lesson  that  breeding  from 
very  young  stock  was  as  detrimental  to  quality  as  breeding  from  that 
which  was  very  old.    'J'he  author,  however,  has  observed  that,  from 

—  79  — 


IMPOTENCE   AND   STERILITY 

a  procreative  standpoint,  moderately  young  blood  is  corrective  of 
old,  and  that  more  mature  blood  is  corrective  of  that  which  is 
over-young. 

In  a  general  way,  sexual  excess  bears  the  same  relation  to 
physical  and  mental  disturbances  as  masturbation.  The  results 
differ  chiefly  in  degree,  and  physical  impairment  from  sexual  excess 
is  more  frequent  than  is  generally  supposed.  Rarely,  indeed,  is 
our  attention  called  to  such  serious  consequences  as  may  result  from 
masturbation,  but  there  are  numerous  reasons  that  satisfactorily 
explain  this.  The  general  belief  is  that  the  extent  of  sexual  indul- 
gence is  to  be  limited  only  by  physical  capacity,  and  that,  unlike 
masturbation,  it  is  harmless  under  all  circumstances.  The  author 
ventures  to  assert,  however,  that  sexual  excess  is  the  most  prolific 
cause  of  that  most  civilized  and  fashionable  of  all  hydraheaded 
diseases,  neiu-asthenia. 

Excessive  sexual  indulgence  is,  of  course,  relatively  infrequent ; 
opportunities  are  not  so  favorable  and  frequent  as  for  masturbation. 
The  habit  of  sexual  excess  is,  to  a  certain  extent,  self -regulating, 
because  of  the  fact  that  satiety,  exhaustion  of  desire,  and  perhaps 
power,  sometimes  occurs  before  serious  physical  injury  has  been 
done,  and  the  individual  must  stop  for  the  time  being.  The  age 
at  which  sexual  excess  is  likely  to  occur  generally  is  far  enough 
advanced  to  escape  the  marked  depression  produced  by  masturba- 
tion upon  the  susceptible  youth.  Continued  excess  will,  however, 
produce  effects  similar  to  those  of  masturbation. 

The  psychic  harmony  experienced  during  normal  intercourse 
undoubtedly  protects  the  individual  to  a  certain  extent,  and  nu- 
merous patients  have  stated  that  intercourse  with  some  females  is 
extremely  exhausting  to  them,  while  wnth  others  they  are  not 
debilitated  by  much  more  liberal  indulgence.  That  this  harmony, 
however,  protects  the  reckless  roue  in  pursuit  of  variety  is  ques- 
tionable. 

It  must  be  remembered  that  frequency  of  coitus  is  not  a  reliable 
criterion  of  sexual  excess.  Frequent  indulgence  may  be  tolerated 
by  some  individuals,  whilst  others  may  be  injured  by  very  infrequent 
indulgence. 

The  extent  to  which  cohabitation  may  be  indulged  in  with  im- 
punity necessarily  varies  with  the  individual,  but,  on  the  average, 
it  may  be  said  that  there  are  few  who  are  not  injured  by  indulgence 

—  80  — 


SEXUAL   EXCESS 

oftener  than  twice  or  thrice  weekly.  One  of  the  author's  patients 
expressed  a  view  that  was  hardly  in  accordance  with  this,  in  the 
statement  that  he  was  "now  very  moderate"  and  could  "get  along 
very  well  with  a  single  nightly  indulgence."  Another  subject  claims 
to  have  achieved  a  record  of  thirty-two  separate  and  perfect  acts 
of  copulation,  with  orgasm,  within  thirty-six  hours,  and  does  not 
consider  the  exploit  remarkable — which  cannot  be  said  of  his  story. 
Much  of  the  nervous  derangement  met  with  in  both  men  and 
women  is  })robably  due  to  excessive  sexual  indulgence,  and  it  is 
certain  that  many  local  diseases  of  women  are  either  produced  or 
enhanced  by  sexual  excess.  Very  little  consideration  is  shown  by 
the  average  man  toward  his  wife;  indeed,  her  welfare  is  usually  a 
secondary  consideration  in  sexual  matters.  X'oluntary  sexual  ex- 
cess on  the  part  of  women  is  rare  and,  where  they  are  especially 
im]iortunate.  there  usually  is  some  physical  or  psychic  defect  to  ac- 
count for  it.  With  men  sexual  excess  is  voluntary,  in  and  out  of 
matrimony.  It  is  the  misfortune  of  many  men  to  believe  that  their 
existence  revolves  around  the  penis  and  testicles  ;  indeed,  a  large 
proportion  of  masculine  humanity  is  imbued  with  the  fatuous  idea 
that  man's  principal  mission  in  life  is  pandering  to  his  own  animal 
appetites. 

The  importance  of  the  relation  of  sexual  excess  and  masturba- 
tion to  the  welfare  of  the  human  race  is  obvious.  We  have  but  to 
review  our  ancient  history  a  little  to  observe  the  deterioration  of 
races  resulting  from  unbridled  licentiousness.  It  would  be  well  for 
both  men  and  women  to  understand  that  if  they  desire  to  perpetu- 
ate their  families  with  good  healthy  stock  they  must  be  moderate 
in  sexual  indulgence.  Every  stock-breeder  understands  this  prin- 
ciple, and  we  may  as  well  learn  to  apply  it  to  the  human  species, 
^larriage  at  a  premature  age  bears  the  same  relation  to  the  quality 
of  the  progeny  as  docs  sexual  excess  in  more  mature  life.  It  has 
been  found  that  breeding  very  young  animals  is  unprofitable,  for 
the  reason  that  the  progeny  are  poorly  develo])ed  and  weak.  In 
a  general  way  it  may  be  said  that  in  the  case  of  the  human  subject 
the  progeny  of  vcr}'  \oung  matings  almost  invariably  are  unfit  for 
ih.e  struggle  for  existence.  The  result,  in  manv  instances,  is  verv 
similar  to  that  of  consanguinity. 

Kxf)eriments   l)y   Cioddard   years   ago   showed   that   in   animals 
fre([uent  copulation  impairs  the  quality  and  quantity  of  the  semen. 

—  81  — 


IMPOTENCE  AND   STERILITY 

Examination  of  the  sperm  ejaculated  by  stallions  at  different  acts 
of  copulation  during  the  same  day  showed  that  the  spermatic  fluid, 
although  dense,  opalescent,  and  of  a  yellowish  or  amber  color  at 
the  first  cover,  became  thinner  and  clearer ;  so  that  after  about  the 
fourth  act  of  copulation  it  was  almost  like  water,  the  spermatozoids 
being  very  few  in  number.  The  experimenter  concluded  that  the 
spermatic  fluid  ejaculated  at  the  first  act  of  copulation  in  the  morn- 
ing would  be  quite  certain  to  fecundate,  while  that  of  later  acts  would 
frequently  fail.  It  therefore  is  better  for  a  stallion  to  be  allowed 
to  cover  only  one  mare  per  day,  the  result  being  mvich  better  than 
where  the  animal  is  obliged  to  cover  four  or  five. 

Individuals  who  indulge  excessively  in  coitus  notice  that  the 
orgasm  after  numerous  acts  of  intercourse  is  attended  by  the  ex- 
pulsion of  little  or  no  semen.  The  fluid  that  attends  ejaculation  after 
repeated  orgasm  is  composed  mainly  of  secretion  from  the  pros- 
tate, Cowper's  glands,  and  urethral  follicles.  This  shows  conclu- 
sively that  the  individual  who  copulates  most  is  likely  to  procreate 
the  least,  and  z'icc  versa. 

The  most  frequent  results  of  sexual  excess  met  with  in  prac- 
tice are  premature  failure  of  sexual  power,  impairment  of  vigor, 
premature  ejaculation,  partial  and  complete  impotence.  These  con- 
ditions will  receive  attention  later  on.  Sexual  perversion ,  in  its 
various  forms  is  one  of  the  rarer  results  of  masturbation  and  sexual 
excess.    Neurasthenia  is  an  almost  constant  result. 

Too  much  stress  cannot  be  laid  upon  inflammation  of  the  verii 
niontaniirti  or  colliculus — /.  c,  colliculitis — in  the  male  as  a  result 
of  abuse  of  the  sexual  function.  A  large  proportion  of  the  cases 
of  impotence  and  premature  ejaculations  with  which  we  meet  are 
due  to  hyperesthesia  of  an  inflamed  colliculus. 

The  author  believes  that  normal  nutrition  and  function  of  the 
various  cell  structures  of  the  body  largely  depend  upon  normal 
quantity  and  quality  of  sex  hormone  supply.  Sexual  excess — indeed, 
all  unphysiologic  use  of  the  sexual  function — produces  aberration 
of  this  exceedingly  vital  principle,  either  as  to  (luantity  or  quality, 
or  both.  If  this  view  be  correct,  the  various  ])henomena  which  we 
term  neurasthenia  may  l)e  readily  understood  in  a  large  propor- 
tion of  cases.  In  view  of  the  hormone  theory,  it  is  rather  difficult 
to  believe  that  either  frequent  masturbation  or  sexual  excess  can 
be   harmless.      W'hen    we   consider   the   importance  to   the   growing 

—  82  — 


SEXUAL   EXCESS 

youth  of  a  proper  nutrition,  which  depends  so  largely  on  proper 
sex  hormone  supply,  the  habit  of  masturbation  assumes  rather  more 
serious  importance  than  usually  is  attributed  to  it.  A  lack  of 
proper  sex  hormone  sup})ly  in  the  female  is  particularly  disastrous 
in  its  effects  upon  the  nervous  system.  Incidentally,  the  elTect  on 
her  pro.^;en_\-  is  a  matter  for  very  serious  consideration.  The 
abundant  supply  of  hormone  provided  by  the  normal  corpus  lutemn 
of  pregnancy  is  not  without  its  uses  in  fetal  development — neither 
is  it  without  its  lessons  for  both  profession  and  laity. 

In  the  author's  opinion  the  evil  general  effects  of  sexual  excess 
are  due  to  several  factors,  siz. :  1st.  Exhaustion  of  sex  hormone 
supply.  2nd.  Vitiation  of  sex  hormone  supply  due  to  imperfect 
elaboration  and  possibly  to  emotional  perversion  of  sex  gland 
chemism.  3rd.  The  perversion  of  bodily  nutrition  in  general  as 
a  secop.dary  effect  of  the  defective  supply  and  perverted  quality 
of  the  sex  hormone.  4th.  Perversion  of  cell  chemism — especially 
that  of  the  secretory  gland  cells — by  excessive  emotional  excitation. 

The  author  believes  that  the  sex  gland  hormone  is  the  most 
important  of  all  in  the  nutritive  hormone  cycle — i.  e.,  that  it  is  the 
keystone  of  the  "nutritive  arch,"  being  the  most  poz^'erful  of  all 
cell  foods  and  stimulants  of  organic  functional  activity,  this  being 
especially  true  of  the  cerebrospinal  and  sympathetic  systems.  If 
this  view  be  correct,  neurasthenia,  with  its  attendant  mental  and 
physical  exhaustion,  may  be,  after  all,  in  many  cases,  in  its  last 
analysis,  merely  a  sympton  of  aberration  of  sex  gland  hormone  pro- 
duction. Where  the  psychic  conditions  attending  the  sexual  act 
are  not  favorable,  a  still  more  marked  aberration  of  the  sex  hormone 
naturally  is  to  be  expected.  This  probably  explains  the  wide  varia- 
tion in  the  effects  of  the  performance  of  the  sexual  function — ef- 
fects varying  from  what  may  be  termed  normal  temporary  lassitude 
to  immediate  profound,  and  subsequently  long  continued,  physical 
and  mental  exhaustion. 

The  sexual  irritability  and  extreme  desire  sometimes  observed 
in  tubercular  subjects — both  male  and  female — at  first  sight  would 
seem  to  controvert  the  view  that  the  effects  of  exhausting  diseases 
in  the  production  of  impotence  are  due  to  perversion  of  the  quality 
and  quantity  of  sex  hormone.  The  answer  probably  is  that  the 
toxins  of  the  tubercular  process  not  only  are  not  so  characteristically 
depressing  as  are  those  of  other  infections,  but  are  more  or  less 

—  83  — 


I^IPOTKNCE  AND   STERILITY 

excitant  to  the  nervous  centers  and  especially  to  the  psycho-sexual 
centers.  Possibly,  too,  for  some  occult  reason,  sex  hormone  pro- 
duction either  is  not  especially  interfered  with  or  is  not  deleteriously 
affected  by  the  toxins  formed  in  the  tubercular  process.  Where 
tuberculosis  apparently  has  the  same  effect  as  other  exhausting 
toxemias  the  superadded  mixed  infection  is  the  probable  explanation. 

UNPHYSIOLOGIC  COITUS. 

Any  method  of  producing  the  orgasm  by  contact  of  the  sexes 
save  the  normal  one  is  unphysiologic,  and  therefore  injurious.  Onan- 
ism, or  premature  withdrav^^al  for  the  purpose  of  avoiding  preg- 
nancy, is  a  common  practice,  and  one  against  which  the  laity  should 
be  warned.  Its  injurious  effects  are,  in  general,  similar  to  those  of 
masturbation  and  sexual  excess.  Coitus  intcrruptus  often  is  in- 
jurious. It  is  a  common  practice  for  the  prevention  of  pregnancy. 
In  the  author's  opinion  it  is  to  a  certain  degree  responsible  for  en- 
larged prostate  in  advanced  life.  It  at  least  often  lays  the  founda- 
tion for  that  distressing  condition.  Prostatic  hyperemia  and  hyper- 
esthesia and  inflammation  of  the  colliculus  seminalis  with  resultant 
premature  ejaculations  and  vesical  irritability  are  produced  by  coitus 
interruptus  more  often  than  by  any  one  cause  that  could  be  men- 
tioned, save  gonorrheal  infection. 

Treatment. 

The  management  of  masturbation  and  sexual  excess  is  largely 
of  a  moral  character,  and  chiefly  prophylactic  rather  than  curative. 

The  first  step  in  the  cure  or  prevention  of  the  vice  of  masturba- 
tion and,  incidentally,  of  sexual  excess,  is  to  improve  the  moral 
tone  and  strengthen  the  intellectual  power  of  the  patient.  The  more 
perfect  the  mental  discipline,  the  easier  it  will  be  to  improve  the 
morale  of  the  individual.  One  of  the  first  steps  should  be  the  inter- 
diction of  all  literature,  classic  or  otherwise,  that  tends  to  foster 
sexual  impulses.  Any  work  that  treats  of  sexual  matters  in  a 
manner  suggestive  of  condonation  of  indulgence  is  injurious,  no 
matter  how  gilded  the  phraseology  may  be.  Strange  as  it  may  seem, 
there  is  a  certain  amount  of  innate  depravity  in  the  human  mind 
which  impels  growing  lads,  and  sometimes  girls,  to  seek  for  pruri- 

—  84  — 


TREATMENT   OF   ^lASTURBATION   AND    SEXUAL   EXCESS 

cncy  in  everything  they  read.  Ivven  the  Bible  is  not  unimpeachable 
regarding  its  effects  upon  the  young ;  indeed,  there  are  few  books 
from  which  a  child  can  obtain  more  pernicious  ideas  of  sexual 
matters  than  from  the  Old  Testament.  Oftentimes  a  natural  and 
])ardona1)le  curiosity  impels  a  child  to  seek  for  information  upon 
a  subject  toward  which  he  instinctively  turns,  but  in  regard  to 
which  he  always  has  been  kept  in  ignorance. 

There  is  one  point  in  sexual  physiology  that  always  should 
be  imi)ressed  upon  our  patients.  The  impression  prevails  among 
young  men  that  exercise  of  the  sexual  function  is  an  absolute  physi- 
cal necessity,  irrespective  of  the  method  of  its  accomplishment.  In- 
deed, it  is  probable  that  some  physicians,  who  certainly  ought  to 
know  better,  foster  this  idea  by  ill-weighed  and  injudicious  coun- 
sel. This  idea  is  most  pernicious  in  its  effects  and  it  becomes  our 
duty  to  correct  it.  Although  no  adult  man  or  woman  under  exist- 
ing social  conditions  is  physiologically  well-balanced  in  a  state  of 
celibacy,  one  may  be  perfectly  healthy  and  physically  vigorous 
while  leading  a  life  of  absolute  continence,  if  the  mind  be  properly 
disciplined  and  the  body  made  completely  subservient  to  the  will. 
The  excuse  of  physical  necessity  too  often  is  a  subterfuge  to  justify 
fornication  and  even  masturbation.  That  such  an  excuse  ever 
should  be  offered  is  striking  testimony  regarding  the  prevalent 
ignorance  of  sexual  physiology.  A  better  education  in  the  ethical 
and  physiologic  aspects  of  the  sexual  function  is  a  crying  neces- 
sity, one  which  the  profession  of  late  has  been  trying  to  meet.'''' 

The  patient  should  be  impressed  with  the  idea  that  sexual  in- 
dulgence is  less  than  a  secondary  consideration  in  the  physical  life 
of  the  individual ;  indeed,  the  average  man  would  be  better  off  with- 
out it  so  far  as  his  mere  physical  welfare  is  concerned.  It  is  un- 
necessary to  existence,  and  its  performance  may  be  held  in  abeyance 
for  very  long  periods,  even  for  life,  without  necessarily  producing 
physical  injury.  When  thus  held  in  abeyance  the  generative  func- 
tion may  be  called  into  action  at  any  time  and  present  no  evidences 
of  deterioration  from  the  compulsory  rest — assuming  that  the 
])hysical  has  been  held  imder  the  control  of  the  moral  nature.  If 
the  mind  be  disturbed  by  sexuality,  as  it  is  prone  to  be  in  our  present 
state  of   society,  enforced  sexual   rest  is  often  productive  of  evil 


*  The  author  has  embodied   his  views  on  this  subject  in  his  work,    "Sex 
llygiene  for  tlie  Male  and  What  to  Say  to  the  Boy." 

—  85  — 


IMPOTENCE  AND   STERILITY 

effects.      When,   in   the   struggle   between  the  moral   and   physical 
natures,  the  will  is  triumphant,  the  result  never  is  detrimental. 

The  old  maxim  that  "idleness  is  the  mother  of  mischief"  is 
especially  applicable  to  the  sexually  depraved,  which  naturally 
leads  to  the  corollary  that  proper  mental  and  physical  training  and 
exercise  are  a  potent  antidote  to  sexuality  of  both  thought  and 
action.  The  individual  who  exercises  both  mind  and  body  to  the 
extent  of  reasonable  fatigue  has  little  desire  for  sexual  indulgence. 
There  is  no  better  anaphrodisiac  than  an  hour  in  the  gymnasium, 
followed  by  a  cold  shower  and  a  vigorous  rub.  The  lad  wlio  takes 
pride  in  his  physique  and  is  attracted  to  athletic  sports  is  seldom 
addicted  to  masturbation  as  compared  with  his  fellows.  The  prac- 
tice of  athletics  necessitates  sexual  abstinence  or  moderation,  as  is 
well  known  to  trainers ;  indeed,  every  athlete  knows  that  after  a 
few  weeks'  training  the  desire  for  sexual  indulgence  is,  in  a  measure, 
lost. 

Physical  exercise,  in  addition  to  diverting  the  superfluous  nerv- 
ous energy  from  the  sexual  organs,  is  also  beneficial  by  lessening  the 
activity  of  secretion  of  semen,  and,  inasmuch  as  distension  of  the 
tnbuli  seuiiniferi  and  seminal  vesicles  by  semen  acts  reflexly  in 
producing  sexual  desire,  anything  that  inhibits  the  seminal  secretion 
necessarily  is  beneficial.  IMuscular  exercise  that  involves  a  certain 
amount  of  attention  and  mental  application,  such  as  boxing,  fencing, 
cricket,  hand-ball,  etc.,  are  particularly  beneficial,  as  tending  to 
divert  the  mind  from  sexual  matters.  The  effect  of  the  mind  upon 
secretion  is  illustrated  not  only  by  the  effect  of  mental  emotion 
upon  the  sexual  organs,  but  upon  the  lacteal,  gastric,  and  salivary 
secretions.  It  is  possible  for  an  individual  to  indulge  immoderately 
in  physical  exercise  and  yet  have  the  mind  constantly  occupied  by 
sexual  affairs.  The  exercises  mentioned  therefore  are  more  likely 
to  secure  the  desired  result  than  are  those  that  merely  involve 
physical  labor. 

With  reference  to  continence  in  youth,  Acton  says: — 

The  argument  in  favor  of  the  Rreat  mental,  moral,  and  physical  ad- 
vantage of  early  continence  does  not  want  for  high  secular  authority  and 
countenance,  as  the  recollection  of  the  least-learned  reader  will  suggest  in 
a  moment.  Let  us  be  content  here  with  the  v/ise  Greek,  who,  to  the  ques- 
tion when  men  should  love,  answered:  "A  young  man,  not  yet;  an  old 
man.   not   at   all;"   and    with   the   still-wiser    Englishman,    who   thus    writes: 

—  86  — 


TREATMENT    OF    SEXUAL   NEURASTHENIA 

"You  may  observe  that  among  the  great  and  worthy  persons  (whereof  the 
memory  remaineth,  either  ancient  or  recent)  there  is  not  one  that  hath  been 
transported  to  the  mad  degree  of  love — which  shows  that  great  spirits  and 
great  business  do  keep  out  this  weak  passion.  .  .  .  By  how  much  the  more 
ought  men  to  beware  of  this  passion,  which  loseth  not  only  other  things, 
but  itself.  As  for  the  other  losses,  the  poet's  relation  doth  well  figure 
amorous  affection,  for  he  quitteth  both  riches  and  wisdom.  .  .  .  They  do 
rest,  who,  if  they  cannot  but  admit  love,  yet  make  it  keep  quarter." 

The  social  habits  of  the  young  require  close  supervision.  Evil 
associates  are  easily  found  in  any  community,  however  respectable. 
It  is  not  unusual  to  observe  a  cluster  of  boys  admiringly  listening 
to  the  lewd  tales  of  some  stable-boy  or  man-of-all-work,  and  the  in- 
struction in  vice  received  at  the  hands  of  his  elders  is  most  per- 
nicious in  its  effects  upon  a  lad  whose  highest  ambition  is  to  be 
mannish — and  he  is  quite  prone  to  mistake  the  depravity  of  his 
teacher  for  manliness. 

Late  hoitrs,  the  dance,  liquor,  tobacco,  high  living,  and  the 
society  of  females  of  questionable  virtue  and  free  manners  foster 
sexual  excitability  and  must  be  avoided.  Suggestive  and  immoral 
plays  have  much  to  do  with  the  vitiated  sexual  tone  of  our  social 
system  and  should  be  interdicted.  When  the  general  health  is 
impaired  tonic  treatment  should  be  instituted.  It  often  is  the  case 
that  the  morale  of  the  patient  does  not  appreciably  improve  until 
his  general  physical  condition  has  changed  for  the  better. 

The  importance  of  careful  attention  to  dietetic  regimen  in  con- 
trolling the  tendency  to  masturbation  and  sexual  excess  can  scarcely 
be  overrated.  The  relation  of  a  stimtilating  and  highly  nutritious 
diet  to  sexual  desire  and  capacity  was  well  understood  by  the 
ancients.  The  old  maxim  — •  "Sine  Baccho  et  Cerere  friget  Venus"  — 
is  as  pertinent  as  it  is  classic.  In  the  lives  of  many  individuals 
Bacchus  and  Venus  go  hand  in  hand  as  dominating  powers.  With 
some  persons  excessive  sexual  desire  is  directly  dependent  upon 
high  living.  Gouty  conditions  of  the  blood  incidental  to  the  latter 
are  especially  likely  to  be  associated  with  irritation  of  the  genito- 
urinary tract,  and  particularly  of  the  nerves  of  the  sexual  sensi- 
bility. If  one  would  remain  continent  he  inust  not  only  abjure  all 
mental  sources  of  sexual  excitement,  but  he  also  must  abstain 
from  stimulants,  tobacco,  highly-seasoned  food  —  in  short,  all 
articles  of  diet  that  tend  to  induce  nervous  irritability.  It  is  probable 
that  a  strictly  vegetarian  regimen  is  the  best  that  can  be  advised  for 

—  87  — 


IMPOTENCE  AND   STERILITY 

an  individual  who  desires  to  remain  continent  both  in  mind  and  body. 
With  our  present  pernicious  social  customs  the  unaided  efforts  of 
the  will  are  not  always  successful  in  conquering  the  lusts  of  the  flesh. 

When  local  diseases  exist,  whether  the  subject  be  male  or 
female,  their  cure  is  essential,  for,  so  long  as  there  exists  any  source 
of  sexual  irritation,  moral  persuasion  will  be  of  little  avail.  Circum- 
cision is  a  valuable  measure,  as  it  relieves  existing  phimosis  and,  by 
uncovering  the  glans  finally  results  in  a  loss  of  sensibility  of  that 
structure  to  a  certain  degree,  and  makes  the  act  of  masturbation 
less  attractive.  In  extreme  cases  in  the  female  amputation  of  the 
clitoris  has  been  known  to  cure ;  this,  however,  is  an  operation  to 
be  very  cautiously  advised.  Baker  Brown,  of  London,  the  originator 
of  the  operation,  performed  it  for  all  sorts  of  nervous  troubles  and 
received  severe  censure  for  his  pains ;  indeed,  he  was  well-nigh 
ostracized  by  his  professional  brethren  —  with  more  sentiment  than 
justice  upon  their  part. 

Circumcision  —  removal  of  the  i)repuce  —  originated  in  re- 
mote ages  as  a  religious  rite.  It  still  is  so  practiced  by  some  peoples, 
notably  by  the  Jews  and  Mohammedans.  The  aborigines  of 
Australia  also  practice  it.  On  this  account,  it  has  been  asserted  by 
some  ethnologists  that  the  native  Australians  are  descendants  of 
one  of  the  Ten  Lost  Tribes  of  Israel.  This  theory  is  as  interesting 
as  it  probably  is  untrue.  Like  some  of  the  native  tribes  of  Africa, 
who  also  practice  circumcision,  the  Australians  show  vestiges  of 
phallism  or  sex  worship,  of  which  circumcision  is  a  ceremonial 
part. 

The  routine  practice  of  circumcision  would  be  most  commend- 
able. Whatever  religious  views  one  may  hold,  it  must  be  conceded 
that  iMoses,  or  whoever  devised  the  operation  for  Jewish  observ- 
ance, was  a  hygienist  of  no  mean  pretentions.  The  Jews  are  social 
hygienists  in  many  ways,  some  of  which  might  well  be  imitated  by 
the  Gentiles,  but  none  of  their  religious  customs  is  quite  so  sensible 
as  the  rite  of  circumcision. 

Circumcision  jiromotes  cleanliness,  ])revents  disease,  and  by 
reducing  over-sensitiveness  of  the  parts  tends  to  relieve  sexual 
irritability,  thus  correcting  any  tendency  which  may  exist  to  improper 
manipulations  of  the  genital  organs  and  the  consequent  acquire- 
ment of  evil  sexual  habits,  such  as  masturbation. 

—  88  — 


CIRCU-MCISION 

Last,  but  not  least,  earl_v  circiuncision  insures  proper  develop- 
ment of  the  parts.  It  is  a  matter  of  common  observation  among 
physicians  that  the  Jew,  upon  the  average,  is  less  frequently  sexually 
mal-developed  than  is  the  Gentile.  The  admirable  custom  of  cir- 
cumcision may  have  much  to  do  with  the  extraordinary  virility  and 
endtirance  of  the  Jewish  race.  It  is  strange  that,  with  the  experience 
and  example  of  this  great  race  before  him,  the  Gentile  has  not 
generally  adopted  as  a  hygienic  custom  the  operation  of  circum- 
cision. It  is  the  author's  opinion  that  parents  zvho  do  not  have  an 
early  circumcision  performed  upon  their  boys  are  almost  criminally 
negligent. 

The  prepuce  is  a  structure  the  function  of  which  evolution  of 
the  race  has  made  obsolete.  It  once  was  urgently  necessary  for 
the  protection  of  the  sensitive  member  of  which  it  forms  a  covering. 
Clothing,  however,  has  relieved  us  of  the  necessity  of  a  means  of 
protection  which  primitive  man  and  his  prehuman  ancestors  found 
very  essential. 

Phimosis,  or  tight  prepuce,  is  often  met  with  in  uncircumcised 
persons.  This  condition  renders  cleanliness  impossible  and  favors 
infection  and  inflammation.  The  irritation  produced  by  a  tight 
prepuce  may  produce  retarded  growth,  extreme  nervousness  and 
irritability,  chorea,  simple  convulsions,  or  even  periodic  attacks 
resembling  epilepsy.  The  author  has  met  with  cases  of  glycosuria 
due  to  phimosis.  The  fretfulness  and  crying  of  young  children  is 
often  due  to  preputial  irritation  —  so  often  that  the  examination 
of  young  children  never  is  complete  until  the  prepuce  has  been 
inspected. 

Circumcision  is  imperatively  demanded  in  all  cases  of  children 
with  nervous  diseases.  Circumcision  should  be  performed  early, 
the  advice  of  the  family  physician  being  the  safest  guide  as  to  the 
time  of  operation.  Circumcision  often  is  necessary  in  adults  for 
the  cure  of  venereal  or  other  disease  of  the  sexual  organs.  Many 
complications  arise  in  venereal  infections  which  would  have  been 
avoided  if  circumcision  had  been  performed  in  early  life. 

In  passing  the  author  would  suggest  that  circumcision  often 
is  improperly  performed.  All  adhesions  should  be  broken  up  and 
a  normal  contour  of  the  corona  glandis  secured.  This  important 
point  frequently  is  overlooked. 


nirOTENCE  AND   STERILITY 

Suggestion  therapy  perhaps  is  the  most  important  of  all 
features  of  the  treatment  of  sexual  irregularities.  Appealing  to 
the  selfishness  of  the  subject  —  i.  e.,  to  his  instinct  of  self-preserva- 
tion and  desire  for  personal  and  social  efficiency  —  rather  than 
moral  suasion,  is  the  logical  line  of  least  resistance.  Quacks  have 
been  of  some  service  by  frightening  youth  into  abandonment  of 
evil  sexual  practices.  Reputable  physicians,  from  far  different 
motives,  may  warn  the  young  person  against  the  evils  of  sexual 
abuses,  whilst  assuring  the  individual  subject  that  no  serious  harm 
thus  far  has  resulted.  The  physician  never  should  ignore,  still  less 
ridicule  the  patient's  symptoms.  He  should  give  them  the  most 
careful  consideration  and  scrupulous  attention,  thus  giving  weight 
to  his  expressed  opinion  of  their  slight  importance  and  favorable 
prognosis.  The  opposite  line  of  management  is  likely  to  drive 
the  patient  into  the  hands  of  the  predatory  quack. 

Children  who  are  mentally  defective  should  be  carefully 
watched,  for  once  the  habit  is  commenced  a  cure  is  almost  impossible. 
The  masturbatory  lunatic  is  rarely  cured  of  his  masturbation.  The 
penis  has  been  blistered  from  glans  to  root,  in  such  cases,  without 
interfering  with  the  habit.  The  straight- jacket  might  perhaps  be 
of  service  temporarily,  but  immediately  he  is  liberated  the  poor 
unfortunate  invariably  begins  his  vicious  practices  again.  In  a 
recent  case  of  the  author's,  internal  and  external  urethrotomy  was 
performed  in  a  young  man  of  24.  Beginning  on  the  third  night 
after  the  operation  he  was  repeatedly  caught  in  the  act  of  masturba- 
tion. In  obstinate  cases,  which  means  the  majority,  the  author 
unhesitatingly  advocates  castration.  Vasectomy  or  ligation  of  the 
vasa  deferentia  may,  however,  be  tried  first. 

Masturbators  sometimes  perform  the  act  during  sleep,  hence 
some  of  them  require  very  careful  watching. 

In  the  primary  defectives,  suprarenal  substance,  apophyseal  — 
pituitary  —  extract  or  substance  (anterior  lobe)  or,  where  hypo- 
thyroidism is  suspected,  thyroid  extract  may  be  of  service.  Epiphy- 
sis— pineal  gland — substance  has  been  recommended  for  defectives 
in  general. 

The  prognosis  in  the  majority  of  vicitims  of  masturbation  is 
good,  but  occasionally  all  means  fail  and  the  patient  becomes  a 
mental  and  i)hysical  wreck.     The  average  boy  or  girl  discovers  the 

—  90  — 


CIRCUMCISION 

perniciousness  of  the  practice  —  thanks  to  quack  Hterature,  as  a 
rvile  —  before  arriving  at  adult  age,  and  stops  it,  with  little  apparent 
physical  disturbance  resulting  from  the  habit  later  on.  Many  are 
permanently  injured  and  present  conditions  in  which  the  real  cause 
is  overlooked. 

Marriage  as  a  remedy  for  masturbation  is  not  to  be  thought  of 
unless  the  subject  is  perfectly  sound,  mentally  and  physically — ^'or 
at  least  practically  so  —  and  of  suitable  age.  Under  any  circum- 
stances the  physician  should  give  the  matter  most  serious  considera- 
tion before  assuming  the  responsibility  of  advising  matrimony. 
There  is  a  wider  latitude  in  the  case  of  women  than  men  in  this 
respect,  as  a  woman  is  seldom  impotent.  Married  masturbators 
are  by  no  means  rare. 

In  a  general  way  the  vices  of  sexual  excess  and  unphysiologic 
coitus  require  the  same  management  as  masturbation.  Fortunately 
the  patients  who  indulge  in  venery  to  excess  are  older  and  possessed 
of  more  powerful  wills  than  the  subjects  of  masturbation  and  are 
more  easily  influenced  by  argument,  especially  if  their  selfishness 
be  appealed  to. 


91  — 


CHAPTER    VL 
Sterilization   and   Asexualization. 

In  a  work  of  this  kind,  it  would  hardly  be  consistent  to  consider 
in  detail,  from  a  sociologic  point  of  view,  the  subject  of  steriliza- 
tion, which  now  is  on  the  topmost  wave  of  public  interest.  Then, 
too,  the  author  elsewhere  has  fully  expressed  his  views. —  (N.  Y. 
Med.  Journal,  April  6,  1912.) 

For  the  purposes  of  this  volume  the  surgical  aspects  of  steriliza- 
tion chiefly  require  consideration,  the  social  therapy  phase  of  the 
process  being"  merely  incidental. 

Re;se;ction  and  Anastomosis  of  the  Vasa  Defurentia. 
(Mechanic  sterilization  and  re-fertilization.) 

These  methods  of  regulating  fertility  demand  special  considera- 
tion : 

Vasectomy  (sterilization  in  the  male)  :  If  a  practical,  easy, 
safe  and  fairly  certain  method  of  anastomosis  is  available,  tempo- 
rary occlusion  of  the  r-asa  dcfcrentia  by  resection  or  ligation  is  a 
logical  indication  in  some  of  the  most  important  conditions  with 
which  the  svn-geon  has  to  deal.  The  author  believes  that  the  opera- 
tion which  he  devised  fulfills  these  indications.  He  has  performed 
it  in  a  number  of  cases  and  with  successful  results  in  all  in  which 
the  conditions  were  favorable.  Due  allowance,  of  course,  should 
be  made  for  cases  which  have  drifted  away  from  observation  soon 
after  operation  and  in  which  the  result  is  unknown.  With  his  present 
perfected  tcchni(|ue  the  author  believes  that  a  large  majority  of  the 
cases  o])erated  should  be  successful.  With  even  a  fairly  successful 
method  of  anastomosis  at  hand,  one  may,  in  the  author's  opinion, 
legitimately  employ  resection  of  the  vasa  deferentia  for  the  relief 
of  numerous  conditions. 

—  92  — 


STERILIZATION    AND    ASEXUALIZATION 

Although  the  indications  for  this  procedure  arc  given  in  the 
appropriate  portion  of  the  text  of  this  work,  they  here  demand 
brief  tabtilation : 

L     Stirgical  injuries  or  trattmatisms  of  the  vas. 

2.  Stricture  of  the  vas. 

3.  Benign  neoplasm  involving  the  vas. 

4.  Incipient  prostatic  enlargement  and  occasionally  where 
prostatectomy  is  refused. 

5.  Obstinate  cases  of  irritability  of  the  vesical  neck. 

6.  Intractable  chronic  prostatitis. 

7 .  Intractable  seminal  vesiculitis. 

8.  Doubtful  ttimors  of  the  testes  in  which  we  desire  to  protect 
the  urinary  way  from  possible  infection. 

9.  Suspected  tuberculosis  of  the  testes,  in  which  operation  on 
the  testicle  itself  is  refused. 

10.  Cases  of  true  spermatorrhea. 

11.  Cases  of  spermatophobia,  in  which  the  mental  condition 
practically  is  a  psychopathy. 

12.  Certain  rare  cases  in  which  involuntary  seminal  emissions 
are  frequent  and  intractable.  (The  author  has  met  with  a  number 
of  cases  of  married  men  afflicted  in  this  way.) 

13.  Obstinate  cases  of  prostatorrhea. 

14.  Prevention  of  propagation  of  the  socially  unfit  and  in- 
efficient from  any  and  all  causes. 

15.  In  confirmed  masttirbators. 

In  some  cases  the  occlusion  of  the  vas  should  be  permanent, 
e.  g.,  in  a  large  class  of  syphilitics,  subjects  of  ttiberculosis,  insane, 
epileptics,  habitual  criminals,  imbeciles,  perverts,  etc.,  and  also  in 
some  local  pathologic  conditions.  \Miere  the  objective  is  perma- 
nent sterilization,  the  entire  available  portion  of  the  duct  shotild 
be  removed  to  prevent  a  possible  restoration  of  continttity  by 
0])eration. 

Laying  aside  all  theoretic  speculation  as  to  the  efl^ects  of  re- 
section of  the  vasa  dcfcrentia,  this  much  is  certain,  viz.,  that  the 
operation  affords  rest  to  the  seminal  vesicles  and  prostate  and 
lessens  their  blood  supply.  The  effect  upon  congestive  and  in- 
flammatory conditions  is  obvious.  In  certain  psychopathic  sub- 
jects—  notably  those  with  prostatorrhea  —  the  cessation  of  visible 

—  93  — 


IMPOTENCE  AND   STERILITY 

discharge  often  secured  by  the  operation  has  a  profound  beneficial 
efifect.  One  of  the  favorable  points  of  double  anastomosis  of  the 
vasa  deferentia  is  that  the  continuity  of  only  one  duct  is  sufficient 
for  fertility,  and  this  doubles  the  chances  of  success  from  the  opera- 
tion. The  length  of  time  that  should  be  allowed  to  elapse  after 
resection  before  anastomosis  is  performed,  of  necessity  varies  with 
the  case. 

Technique:  After  careful  shaving  and  asepsis  of  the  scrotum, 
the  vas  is  isolated  sub-scrotally  with  needle  pointed  forceps*  above 
and  below  the  point  of  election  and  exposed  by  an  incision  one-half 
an  inch  to  two  inches  in  length.  Where  temporary  sterilization  is 
desired,  the  shorter  incision  should  be  employed.  The  sheath  of 
the  cord  next  is  carefully  incised  and  the  edges  of  the  sheath  wound 
caught  with  snap  forceps.  The  vas  now  is  separated  carefully 
from  its  fascial  envelopments  and  divided  and  the  requisite  portion 
excised.  In  the  author's  resections,  where  anastomosis  at  some 
future  time  is  anticipated,  the  vas  merely  is  severed,  ligated,  and 
joined,  so  that  the  ends  overlap.  This  prevents  re-establishment 
of  continuity  —  granting  this  to  be  possible,  —  and  enables  the 
surgeon  readily  to  find  the  two  ends  when  he  desires  later  to  make 
a  true  anastomosis.  Care  should  be  taken  in  such  cases,  not  to 
strip  the  vas  more  than  is  necessary  to  resect  it.  Its  sheath  really 
should  be  preserved,  so  far  as  possible,  to  prevent  atrophy  of  the 
distal  portion.  The  operation  is  concluded  by  stitching  with  horse 
hair  —  interrupted  —  or  with  fine  catgut  —  continuous  — and  cover- 
ing the  wound  with  bismuth  sub-iodide,  gauze  and  collodion. 

Anastomosis  of  the  vasa  deferentia:  This  is  demanded  under 
three  conditions,  viz. : 

1.  Accidental  severing  of  the  duct,  either  from  traumatism  or  dur- 
ing the  performance  of  surgical  operations. 

2.  After  resection  for  the  relief  of  stricture  of  the  vas  or  for  the 
removal  of  new  growths. 

3.  Where  the  vas  has  been  resected  on  one  or  both  sides  for  ther- 
apeutic purposes  and,  the  object  of  the  resection  having  been  accomplished, 
restoration  of  the  continuity  of  the  duct  is  desired. 

The  vas  is  exposed  as  in  resection,  using  a  longer  incision  than 
in  temporary  sterilization.  Where  previous  resection  has  been 
performed   according   to   the   author's   method,    a   small   nodule   is 


♦Suggested  by  Dr.  W.  T.  Belfield. 

—  94 


STERILIZATION   AND   ASEXUALIZATION 

found  and  excised  at  the  junction  of  the  severed  ends  of  the  vas. 
Both  ends  of  the  vas  now  are  probed  with  a  fine  fiHform  bougie, 
or  a  bit  of  silkworm  gut,  —  the  latter  suggested  by  Dr.  Emil  Ries  — 
to  determine  whether  the  lumen  of  the  vas  is  patent.  The  duct  is 
now  bent  at  about  a  right  angle  and  a  sharp-pointed  probe  or 
smooth  broach,  or  a  long,  round,  fine  needle  passed  through  the  wall 
of  the  vas  about  1^  inches  from  the  cut  proximal  end.  A  straight 
strand  of  the  largest  sized  silkworm  gut  now  is  passed  into  the 
lumen  of  the  proximal  end  of  the  vas  and  made  to  emerge  at  the 
opening  made  by  the  broach  or  needle.  A  hypodermic  needle  may 
be  used  and  the  gut  passed  through  it.  The  gut  is  drawn  through 
the  puncture  in  the  wall  of  the  vas  until  about  three  inches  of  it 
portrudes.  The  other  end  of  the  strand  of  gut  is  threaded  into 
the  distal  portion  of  the  vas  and  the  two  ends  of  the  severed  duct 
brought  together  over  the  "coupling"  thereby  formed. 

A  fine  catgut  stitch  now  is  inserted  in  the  vas  at  the  line  of  the 
anastomosis  and  tied  securely.  A  second  stitch  is  placed  directly 
opposite  the  first.  In  the  author's  opinion  these  stitches  really  are 
made  unnecessary  by  the  next  step  of  the  operation,  although  they 
make  assurance  doubly  sure  in  maintaining  apposition  of  ends  of 
the  duct.  The  edge  of  the  fascia  of  the  cord  next  is  stitched  upon 
itself  so  as  to  enwrap  the  vas  in  a  distinct  sheath.  The  opposite 
edge  of  the  fascia  finally  is  stitched  over  the  cord  to  the  sheath  just 
made  for  the  vas.  The  vas  for  about  an  inch  or  more  beyond  the 
line  of  union  of  the  duct  is  thus  enveloped  in  a  snugly  fitting  sheath 
of  fascia  that  securely  holds  the  ends  of  the  tube  and  prevents 
them  from  slipping  apart,  protecting,  in  addition,  the  line  of 
junction. 

The  free  strand  of  silkworm  gut  is  passed  through  a  small 
puncture  in  the  skin  just  above  the  upper  angle  of  the  wound.  It 
is  not  wise  to  use  a  needle  for  this  purpose,  lest  the  portion  of  the 
silkworm  gut  that  occupies  the  lumen  of  the  vas  be  disturbed.  If 
desired,  the  strand  of  gut  also  may  be  made  to  emerge  from  the 
distal  portion  of  the  duct  wall  and  the  corresponding  portion  of 
the  scrotum. 

The  skin  wound  now  is  sutured  in  the  usual  manner,  with  fine 
catgut  or  horse-hair,  and  the  ordinary  dressings  applied.  On  the 
tenth  day  the  strand  of  silkworm  gut  is  withdrawn.     A  very  fine 

—  95  ~ 


IMPOTENCE  AND   STERILITY 

whalebone  filiform  bougie  may  be  used  instead  of  silkworm  gut  for 
coupling  the  vas.     The  author  also  has  used  silver  wire. 

The  advantages  claimed  for  the  foregoing  briefly  are:  1,  Accu- 
rate anastomosis,  not  to  be  secured  in  any  other  way ;  2,  immobility 
of  the  anastomosed  vas,  so  necessary  to  union ;  3,  maintenance  of 
patency  of  the  vas,  which  is  not  insured  by  any  other  method ;  4, 
simplicity,  ease  and  rapidity  of  performance. 

The  earlier  anastomosis  is  performed  after  resection  of  the 
vas,  the  better,  for,  despite  careful  manipulation  during  resection, 
atrophy  of  the  distal  portion  possibly  may  follow  resection  and 
make  subsequent  anastomosis  impossible. 

In  the  female,  the  correlative  of  vasectomy  is  resection  of  the 
Fallopian  tubes.  This  is  a  more  logical  method  of  preventing  pro- 
creation than  is  sterilization  of  the  husband.  For  example,  steriliza- 
tion of  the  husband  for  the  purpose  of  preventing  conception  by  a 
wife  who  is  permanently  unfit  to  bear  children,  is  as  unfair  as  it  is 
illogical,  ]:)resupposing-.  as  it  does :  a,  that  a  perfectly  normal  male 
should  be  put  out  of  the  running  sexually  because  his  present  mate 
is  inherently  and  permanently  unfit  for  maternity  ;  b,  that  operation 
for  restoration  of  the  fertility  in  the  male  is  infallible. 

Conditions  may  be  such  that  both  parents  should  be  sterilized, 
for  either  may  marry  again. 

From  reading  most  of  the  dissertations  hitherto  published  on 
sterilization  as  a  remedy  for  social  ills,  one  might  conclude  that 
criminals  are'  monosexual.  It  must  be  remembered,  however,  that 
the  sterilization  of  the  male  criminal  does  not  complete  the  task 
of  social  defense  via  sex  mutilations.  The  female  criminal  also 
should  be  sterilized  by  removal  of  the  Fallopian  tubes.  The  ovaries 
should  be  preserved.  Care  should  be  taken  to  make  the  resection  of 
the  tubes  complete,  lest  regeneration  occur.  The  uterine  tubal 
stump  should  be  cauterized  with  pure  carbolic  acid  to  insure  its 
obliteration.  In  many  instances  in  married  life,  the  female,  not  the 
male,  should  be  sterilized  to  prevent  conception.  TJic  healthy  hus- 
band never  should  be  sicriliced  to  save  a  degenerate  or  diseased 
wife  from  child-bearing,  for,  zvhile  subsequent  anastomosis  of  the 
vas  is  likely  to  be  successful,  it  cannot  be  guaranteed,  and  the 
capacity  for  fatherhood  under  more  favorable  circumstances  possibly 
might  be  lost. 

—  96  — 


CHAPTER    VII. 
Sterility  and  Impotence. 

Gkneral  Considerations. — As  a  result  of  certain  organic  or 
functional  disturbances  of  the  sexual  organs  the  procreative  function 
may  fail  of  its  object.  To  the  sexual  perturbations  that  are  responsi- 
ble for  inability  to  propagate  the  species  the  terms  impotence  and 
sterility  are  applied.  These  conditions  may  be  found  in  both  male 
and  female. 

As  a  preliminary  to  the  consideration  of  the  diseases  afifecting 
the  mechanics  of  the  procreative  act  some  consideration  of  its 
physiologic  phenomena  is  essential. 

Erection:  During  normal  erection  the  penis  becomes  firm  and 
erect,  from  engorgement  with  blood  —  active  hyperemia.  The 
erectile  tissue  of  the  corpora  cavernosa  and  the  corpus  spongiosum 
is  peculiarly  adapted  to  this  transformation  of  the  organ,  being 
composed  of  relatively  large  spaces  inclosed  in  trabecule  of  connect- 
ive and  plain  muscle  tissue  which  support  an  abundance  of  arteri- 
oles —  the  so-called  erectile  tissue.  It  is  generally  agreed  that  the 
work  of  Eckhard  demonstrated  the  essential  facts  in  the  mechanics 
of  erection.*  He  showed  by  experiment  on  the  dog,  that  stimulation 
of  the  nervi  crigentes  causes  erection.  These  nerves  are  composed 
of  autonomic  hbers  arising  from  the  sacral  portion  of  the  spinal 
cord.  They  arise  from  the  first  to  the  third  sacral  nerves  on  each 
side  and  help  to  form  the  pelvic  plexus.  They  contain  vasodilator 
fibers  to  the  penis,  as  well  as  to  the  rectum  and  anus.  When  these 
fibers  are  stimulated  there  is  a  large  dilatation  of  the  arterioles  in 
the  erectile  tissue  of  the  penis  and  a  greatly  augmented  blood-fiow 
to  the  organ.  If  the  erectile  tissue  is  cut  or  the  dorsal  vein 
opened,   the   blood-flow   under  usual   conditions  is   a   slow   stream, 


*  Howell,  Text  Book  of  Physiology. 

—  97 


IMPOTENCE  AND   STERILITY 

but  when  the  nerviis  erigens  is  stimulated  the  outflow  is  very  greatly 
increased,  eight  to  fifteen  times  more  blood  flowing  out  of  the  organ. 
Erection  therefore  is  due  essentially  to  a  vascular  dilatation  of  the 
small  arteries  whereby  the  cavernous  spaces  become  filled  with 
blood  under  considerable  pressure,  the  cavernous  tissue  being  dis- 
tended to  the  limits  permitted  by  their  tough,  fibrous  walls.  It 
seems  probable  that  the  turgidity  or  rigidity  of  the  congested  organ 
is  completed  by  a  partial  obstruction  of  the  venous  outflow,  which 
is  effected  by  a  compression  of  the  efferent  vein  by  means  of  the 
intrinsic  muscles  (ischio-  and  bulbocavernosus)  and  possibly  by  the 
intrinsic  musculature  as  well.  This  compression  does  not  occlude 
the  blood  flow  completely,  but  greatly  increases  the  venous  pressure. 
Commenting  on  the  foregoing,  Hovv^ell  says :  "This  explanation 
of  the  act  of  erection,  while  no  doubt  correct,  so  far  as  it  goes,  leaves 
undetermined  the  means  by  which  the  dilation  of  the  small  arteries 
is  produced.  Vasodilator  nerve  fibers  in  general  are  assumed  to 
produce  a  dilation  by  inhibiting  the  peripheral  tonicity  of  the 
arterial  walls.  If  this  explanation  is  applied  to  the  case  under 
consideration  it  forces  us  to  believe  that,  throughout  life,  except 
for  the  very  occasional  acts  of  erection,  the  arteries  of  the  penis  are 
kept  in  a  constant  condition  of  active  tone.  Moreover,  on  this  view 
we  should  expect  that  section  of  the  vaso-constrictor  fibers  to  the 
penis,  by  abolishing  the  tone  of  the  arteries,  also  would  cause  erec- 
tion. These  constrictor  fibers  arise  from  the  second  to  the  fifth 
lumbar  spinal  nerves,  and  reach  the  organ  by  way  of  the  hypogastric 
nerve  and  plexus  and  the  pudic  nerve.  No  such  result  of  their 
section  is  reported,  and  it  seems  that,  in  the  matter  of  erection,  the 
actual  mechanism  of  the  great  dilatation  caused  by  the  nervi  erigentes 
still  contains  some  points  that  need  investigation." 

The  Reflex  Apparatus  of  Erection  and  Hjacnlation:  The 
dilation  of  the  arteries  of  the  penis  during  erection  normally  is  a 
reflex  act,  effected  through  a  center  in  the  lumbar  cord.  This  center 
may  be  acted  upon  by  impulses  arising  in  some  part  of  the  genital 
tract  —  from  the  testes  themselves.  Mechanic  stimulation  of  the 
glans  leads  to  erection,  and  Eckhard  showed  in  dogs  that  section  of 
the  pudic  nerve  prevents  this  reflex  from  occurring,  proving,  there- 
fore, that  the  sensory  fibers  concerned  run  in  the  pudic  nerve. 
Stimulation  of  these  latter  fibers  leads  also  to  erotic  sensations  and 

—  98  — 


STERILITY    AND    IMPOTENCE— GENERAL    CONSIDERATIONS 

eventually  to  the  completion  of  the  sexual  orgasm.  This  latter  aci 
brings  about  the  forcible  ejection  of  the  sperm  through  the  urethra. 
It  is  initiated  by  contraction  of  the  musculature  of  the  z'asa  deferen- 
tia,  ejaculatory  duct,  the  seminal  vesicles,  and  the  prostatic  gland, 
which  force  the  spermatozoa,  together  with  the  secretions  of  the 
vesicles  and  prostate  gland,  into  the  urethra,  whence  they  are  ex- 
pelled in  the  culminating  stage  of  the  orgasm  by  the  rhythmical 
contractions  of  the  ischiocavernosiis  and  biilhocavernosus  muscles, 
together  with  the  constrictor  urethra.  The  immediate  center  for 
this  complex  reflex  is  assumed  to  lie  in  the  lumbar  cord,  since, 
according  to  the  experiments  of  Goltz,  mechanic  stimulation  of  the 
glans  in  dogs  causes  erection  and  seminal  emission  after  the  lumbar 
cord  is  severed  from  the  rest  of  the  central  nervous  system.  Under 
ordinary  conditions  the  act  is  accompanied  by  strong  psychical  re- 
actions which  indicate  that  the  cortical  region  of  the  cerebrum  is 
involved.  It  is  interesting  in  this  connection  to  find  that  electrical 
stimulation  of  a  definite  region  in  the  cortex  of  dogs  may  cause 
erection  and  ejaculation.  It  is  evident  from  the  foregoing  that  either 
mechanic  or  psychic  causes,  or  both,  may  interfere  with  erection, 
as  indeed  is  clearly  shown  by  the  varying  clinical  conditions  met 
with  in  the  study  of  impotence.  It  further  is  evident  that  any  condi- 
tion, mechanic  or  psychic,  that  disturbs  the  equilibrium  of  the  circu- 
lation of  the  erectile  tissue  may  cause  impotence.  It  seems  logical 
to  infer  that  either  interference  with  the  penile  blood  intake  or  ex- 
cessive outflow  may  impair  the  erectile  power. 

Impotence  implies  inability  to  consummate  the  sexual  act.  This 
inability  may  be  due  to  organic  or  psychic  causes,  or,  as  it  is  usually 
expressed,  may  be  real  or  imaginary  in  either  sex.  Irrespective  of 
the  underlying  cause,  the  material  result  so  far  as  copulation  is 
concerned  is  of  a  purely  mechanic  nature.  The  male  fails  to  pene- 
trate the  vagina  of  the  female  because  of  failure,  imperfection,  or 
transitory  nature  of  erection,  or  penile  deformities  —  congenital  or 
acquired  —  that  make  intromission  impossible.  The  condition  is  rare 
in  the  female,  for  the  reason  that,  so  long  as  she  presents  a  more  or 
less  suitable  recc[)tacle  for  the  male  organ,  she  does  not  usually 
consider  h('i>c]f  impotent.  Impotence  in  the  female  usually  implies 
eitlicr  some  deformity  or  disease  that  produces  atresia  of  the  vagina 
or    some    local    inflammatory    affection  —  acute    or    chronic  —  that 

—  99  — 


IMPOTENCE   AND   STERILITY 

gives  rise  to  vaginismus  ;  /.  e.,  pain  and  spasm  dvn-ing  attempts  at 
copulation.  In  neurotic  or  hysteric  subjects  this  condition  may  occur 
independently  of  local  inflammation  or  atresia. 

Sterility  practically  implies  incapacity  for  fecundation.  Copula- 
tion and  even  orgasm  may  be  perfect,  yet  fecundation  cannot  occur 
because  of  organic  defect  in  one  or  both  parties  to  the  sexual  act. 
These  defects  are  several,  and,  broadly  speaking,  are  of  two  kinds: 
(a)  mechanic  and  (b)  nutritive.  In  the  first  category  are  (1)  condi- 
tions in  which,  although  copulation  is  normal,  and  both  ovule  and 
sperm-cell  are  healthy,  certain  local  conditions  prevent  them  from 
meeting  at  the  proper  time;  (2)  the  germ-cell  and  sperm-cell  having 
met,  their  blending  is  prevented;  or  (3)  the  ovule  having  been 
fecundated,  certain  local  conditions  prevent  the  development  of  the 
ovum. 

In  the  second  category  are  various  more  or  less  obscure  condi- 
tions that  affect  the  vitality  of  the  ovule  and  the  vitality  and  activity 
of  the  spermatozoa.  Independently  of  constitutional  weakness  of 
either  ovule  or  spermatozoon,  or  both,  there  probably  is  a  lack  of 
affinity  between  them  in  some  cases  that  either  prevents  them  from 
blending  or,  if  blending  occurs,  makes  the  union  unproductive.  This 
lack  of  affinity  heretofore  has  been  regarded  as  "mysterious."  The 
author  believes  that  his  application  of  the  hormone  theory  in  great 
measure  solves  the  ])roblem.  That  certain  vitiated  conditions  of 
ovule  or  spermatozoa  may  make  the  one  deadly  to  the  other  is 
j)robable  in  the  light  of  the  hormone  theory. 

The  author's  theory  of  hormone  incompatibility  reduces  the 
problem  of  infertility  to  a  purely  bio-chemical  basis  in  many  other- 
wise inexplicable  cases.  This  later  will  be  fully  exj^atiated  upon. 
Suffice  it  to  say  here  that  this  lack  of  affinity  may  be  primary  or 
secondary  :*  /.  e.,  inherent  to  the  cell  determinants,  or  acquired  by 
certain  extraneous  conditions,  c.  s^.: 

f       Consanguinity 

J        Individual  incompatability       (   Physical 
Inherent  conditions        '\         ,-   ^  ^u  ■{    v      u- 

I'vxtreme  youth  (   Psychic 

Senililv 


I 


•  III    tlio    matter    of    sex    airmities    in    general,    Goethe's    iio\cl.    "Eleetivo 
Airinities,"  will  be  recalled. 

—    100  — 


STKRTUTV    AND    IMPOTENCE-GENERAL    CONSIDERATIONS 

Fear  of  consequences,  notably  of  preg- 
nane}- or  of  contracting  disease. 

Aversion   for  the  sexual  act 

Disgust  for  the  partner  in  the  act 

Painful    conjugation    (in   the    female) 

Anger 

Jealousy 

Psychic  shock,  before,  during  or  soon  after 
conjugation 


Acquired   conditions 
a.     Psychic 


b.     Tox 


I 


Anemias  and  Cachexias 

Narcotics 

Alcohol 

Toxemia   from   disease 


In  breeding  domestic  animals,  notably  fowls,  the  author  has 
noted  the  greatest  variation  in  fertility  in  crossing  different  strains, 
as  well  as  a  lack  of  uniformity  in  the  resttlts  shown  in  the  progeny 
of  different  strains  of  the  same  pure-blooded  variety.  Prior  to  the 
discovery  of  internal  secretions,  the  author  was  wont  to  explain  stich 
phenomena  by  the  inharmoniotis  blending  of  some  subtle  bio-cheinical 
blood  principle,  by  virtue  of  which  the  blood  of  certain  strains  when 
mingled  "precipitated,"  so  to  s]^eak,  various  qualities  —  good  or 
bad  — •  which  do  not  appear  when  these  strains  are  crossed  with 
others  of  the  same  variety.  Sports  and  type  reversions  perhaps 
may  thus  be  explained. 

One  of  the  experiences  related  by  certain  breeders  of  blooded 
stock,  for  which  no  logical  explanation  hitherto  has  been  offered, 
is  the  apparent  permanent  "tainting"  of  the  female  —  for  breeding 
purposes  —  that  has  been  claimed  to  result  from  a  mongrel  cross. 
Some  extensive  and  careftil  breeders  are  so  convinced  of  this  that 
they  no  longer  tise  for  breeding  purposes  a  thoroughbred  female 
that  ever  has  been  impregnated  by  a  mongrel,  because  of  the  alleged 
fact  that,  even  when  subsequently  bred  constantly  to  thoroitghbred 
males,  a  "throw  back"  of  the  progeny  to  the  characteristics  of  the 
ill  bred  previous  sire  at  any  time  may  occtir.  Instances  have  been 
reported  of  human  females  wdio  have  procreated  children  presenting 
the  characteristics  of  the  male  parent  of  children  born  in  a  previous 
marriage. 

(".ranting  that  these  incidents  —  in  both  the  lower  animals  and 
human   beings  —  are   atithentic,   may   they   not   be   explained   by   a 

—  101  — 


IMPOTENCE  AND   STERILITY 

more  or  less  enduring  effect  of  the  combined  sex  hormones  of  the 
previous  mating  upon  the  ovary  of  the  female? 

The  theory  of  a  psychic  impression  cause  hardly  would  do  in 
the  case  of  the  lower  animals,  and  in  the  case  of  the  human  being 
would  act,  if  at  all,  by  modifying  for  a  time  the  hormone  production 
of  the  female  sex  glands.  This  would  be  more  logical  than  the 
popular  maternal  impression  theory. 

There  are,  to  be  sure,  several  possible  sources  of  error  in  the 
alleged  clinical  observations  —  such  as  accidental  new  sources  of 
undesirable  paternity  in  the  case  of  the  lower  animals,  and  both  auto- 
and  hetero-suggestion  in  the  case  of  the  human  female. 

The  author  is  free  to  say  that  he  has  had  no  opportunity  of 
verifying  the  alleged  facts  involved  in  the  foregoing,  and  that,  in 
extensively  breeding  pure  bred  fowls  where  accidental  contamina- 
tions have  occurred,  he  never  has  observed  such  phenomena.  An- 
other point  worthy  of  consideration  is  the  ever  present  possibility 
that  the  sire,  or  dam,  or  both,  may  have  an  inherited  "cold"  strain 
which  crops  out  under  the  combined  sex  hormone  influences  of  cer- 
tain matings,  and  results  in  what  the  author  unconventionally 
has  termed  a  "precipitation"  of  the  objectionable  ancestral  character- 
istics. 

A  moment's  reflection  will  show  that  both  male  and  female 
may  be  potentially  fertile,  although  practically  sterile.  It  also 
may  be  seen  that,  although  sterile  with  one  person  of  the  opposite 
sex,  either  male  or  female  may  be  fertile  with  others.  Incompati- 
bility of  otherwise  normal  hormones  is  the  author's  explanation  of 
this. 

Sterility  and  impotence  may  or  may  not  be  combined.  Thus, 
as  a  consequence  of  removal  of  the  testes  the  male  may  be  entirely 
shorn  of  sexual  desire,  and  is  necessarily  at  the  same  time  made 
incapable  of  producing  the  germinal  material  necessary  for  fecundat- 
ing the  ovule.  On  the  other  hand,  the  testes  may  be  removed  in 
some  cases,  and  yet  for  a  greater  or  less  length  of  time  the  potency 
of  the  individual  remains  unimpaired.  Stallions  that  are  gelded  late 
are  likely  to  retain  their  sexual  desire  and  power;  if,  however, 
castration  be  performed  when  they  are  young,  they  are  rendered 
both  impotent  and  sterile.  It  is  nothing  unusual  for  owners  of  stock 
to  keep  on  hand  a  horse  that  has  been  gelded  late  in  life,  for  the 

—  102  — 


STERILITY    AND    IMPOTENCE— GENERAL    CONSIDERATIONS 

purpose  of  gratifying  the  marcs  during  the  period  of  horsing.  In 
horses  of  this  kind  emissions  occur  of  a  character  somewhat  re- 
sembhng  normal  semen,  although  spermatozoa  are  necessarily  absent. 
The  secretion  emitted  under  such  circumstances  is  furnished  by  the 
mucous  glands  of  the  urethra,  the  prostatic  follicles,  and  Cowper's 
glands.  The  possibility  of  retention  of  the  power  of  copulation  after 
castration  is  so  well  recognized  in  the  harems  of  the  East  that 
eunuchs  from  whom  both  testes  and  penis  have  been  removed  bring 
a  much  higher  price  in  the  market  than  those  who  have  been  merely 
castrated.  Individuals  who  are  absolutely  incapable  of  emitting 
true  semen  may  be  perfectly  potent.  Such  cases  are  an  illustration 
of  potency  combined  with  sterility. 

The  explanation  of  the  continuance  of  mechanic  sex  capacity 
after  castration  or  loss  of  the  testes,  probably  is  the  fact  of  perfect 
development  of  the  genito-spinal  and  cerebral  sex  centers  and  sym- 
pathic  nerve  supply,  which  continue  to  act  for  a  greater  or  less 
length  of  time  after  loss  of  the  secreting  organs.  Possible  vicarious 
action  of  other  hormones  in  the  endocrine  cycle  is  worthy  of  con- 
sideration. The  author  would  suggest  that  there  is  a  prostatic  hor- 
mone which  is  more  or  less  essential  to  sexual  activity  and  which  acts 
vicariously  until  such  time  as  the  prostate  atrophies  —  as  the  normal 
prostate  is  likely  to  do  —  after  castration.  Much  depends  on  the 
continuance  of  the  sexual  habit  —  disuse  is  detrimental  —  and  on 
the  psychic  effect  of  loss  of  the  testes. 

A  very  important  source  of  error  in  the  case  of  the  oriental 
eunuch  and  castrated  animals,  and  of  human  males  who  have  lost 
the  testes  as  a  result  of  accident  or  disease,  is  that  a  certain  amount 
of  testicular  tissue  may  escape  removal  or  destruction,  a  very  small 
amount  being  effective  in  perpetuating  virility.  A  peculiar  case 
has  been  related  of  an  oriental  chief  eunuch,  who  proved  to  be  the 
father  of  a  number  of  infants  presented  to  a  certain  polygamous 
patriarch  by  the  ladies  of  the  harem.  It  transpired  that,  when  the 
eunuch  was  "castrated"  as  a  young  lad,  the  scrotum  only  was  re- 
moved, the  testes  being  temporarily  retained  —  cryptorchidism  — 
only  to  descend  later,  with  embarrassing  results.  The  person  of 
the  chief  eunuch  being  sacred,  he  was  exiled  —  in  an  iron  box  by 
sea.  The  box  "accidentally"  was  lost  overboard  in  a  convenient 
gale. 

—  103  — 


IMPOTENCE  AND   STERILITY 

When  cither  animal  or  man  is  completely  castrated  prior  to 
the  completion  of  se.v  development,  im.potence  invariably  results. 
That  sterility  always  follows  castration  in  either  sex  at  any  age  is 
self-evident. 

Sterility  sometimes  is  due  to  disparity  of  development  of  the 
sexual  organs  in  husband  and  wife.  The  author  has  met  with 
several  cases  of  such  physio-sexual  "misfits." 

Individuals  in  whom  the  testes  are  intact,  the  penis  having  been 
removed,  necessarily  are  impotent,  although  vmder  favorable  circum- 
stances they  hardly  could  be  said  to  be  sterile.  They  might  be 
termed  potentially  fertile  and  dynamically  sterile.  If  it  were  prac- 
ticable to  bring  the  semen  of  such  individuals  in  contact  with  the 
healthy  ovule,  fecundation  would  be  as  likely  to  occur  as  in  indi- 
viduals possessing  perfect  virile  power.  The  same  holds  true  of 
men  whose  epididymes  vasa  deferentia,  or  ejaculatory  ducts  have 
been  occluded  by  injury  or  disease.  In  time  the  testes  may  fail 
to  elaborate  fertile  semen,  but  at  first  it  certainly  is  formed.  In- 
dividuals who  from  various  causes  are  unable  to  secure  or  main- 
tain an  erection,  nevertheless  may  be  capable  of  impregnating  the 
female,  for  such  persons  are  likely  to  have  emissions  and  the  ejacu- 
lated fluid  may  be  capable  of  fecundating  the  ovule.  It  is  not  even 
necessary  that  the  semen  thus  ejaculated  should  be  thrown  into  the 
vagina,  as  has  been  shown  in  instances  in  which  contact  and  emis- 
sions without  penetration  have  been  permitted  by  the  female,  with 
resulting  pregnancy.  It  appears  to  be  possible  for  pregnancy  to 
occur  when  the  semen  is  deposited  only  upon  the  external  female 
genitals,  although  in  some  instances  the  recorded  evidence  is  some- 
what dubious. 

Stivriuty   in  THE  Male. 

Sterility  in  the  male  has  been  sadly  neglected  by  the  profession. 
When  consulted  with  reference  to  unfruitfulness  in  married  life,  the 
medical  man,  as  a  matter  of  routine,  usually  attributes  the  difficulty 
to  some  inherent  incapacity  or  acquired  morbid  condition  of  the 
female.  It  is  probable  that  much  of  the  effort  that  is  directed  to  the 
cure  of  sterility  in  women  is  misapplied,  the  husband  and  not  the 
wife  being  at  fault.  If  the  direct  and  remote  results  of  gonorrheal 
infection  in  both  male  and  female  be  given  due  consideration,  the 

—  104  — 


STERILITY   IN   THE   MALE 

responsibility  of  the  male  sex  in  the  matter  of  sterility  will  at  once 
be  seen  to  be  considerable.  It  has  been  stated  by  eminent  gynecolo- 
gists —  with  reason  and  great  moderation  —  that  at  least  one-sixth 
of  the  cases  of  sterility  that  are  brought  to  the  attention  of  the 
physician,  are  due,  not  to  difficulties  in  the  female,  but  to  morbid 
conditions  in  the  male.* 

Etioloc.v. — Sterility  in  the  male  is  due  to:  I.  Some  morbid 
condition  that  perverts  the  vitality  of  the  seminal  fluid  and  renders  it 
incapable  of  fecundating  the  ovum.  2.  Conditions  obstructing  the 
escape  of  the  semen  from  the  ejaculatory  ducts.  3.  Conditions 
preventing  the  proper  deposition  of  the  semen  in  the  vagina.  4.  De- 
fective development  of  the  testes  is  likely  to  give  rise  to  sterility  on 
account  of  the  functional  inactivity  of  the  imperfect  organs. 
5.  Cryptorchidism.  6.  Defective  or  perverted  quality  or  insuffi- 
cient supply  of  sex  hormone  due  to  conditions  4  and  5  or  to 
acquired  local  general  conditions  which  disturb  sex  hormone  pro- 
duction. 

.\ccording  to  Kehrer,  the  cause  of  childless  marriages  is  to  be 
sought  much  oftener  on  the  side  of  the  man  than  heretofore  has 
been  the  custom.  This  statement  is  based  upon  investigations  of  the 
semen.     Kehrer  investigated  ninctv-six  cases : 

In  3.12  per  cent,  there  existed  inability  to  copulate;  in  all  such  cases 
tliere  hail  been  prececHni;-  masturbation. t  Tlio  men  suffered  from  frequent 
pollutions,  or  the  ejaculations  were  premature  and  the  penis  could  not  be  in- 
serted into  the  vagina.  In  these  cases  Kehrer  claims,  impregnation  may  re- 
sult, if  before  the  attempt  at  coitus  a  speculum  be  introduced  into  the  vagina. 
In  several  cases  conception  was  obtained  by  this  maneuver.  In  31.21  per 
cent,  azoospermia — absence  of  sperm.atozoa — existed.  In  most  of  these 
cases  gonorrhea,  with  unilateral  or  bilateral  orchitis,  had  preceded.  The 
author  lays  particular  stress  upon  occlusion  of  the  ejaculatory  ducts  through 
gonorrheal  prostatitis.  But  azoospermia  was  also  found  where  no  disease 
of  the  sexual  organs  had  occurred,  and  where  nothing  abnormal  in  the  genital 
organs  could  be  demonstrated.  Oligospermia — deficient  quantity  of  semen 
— was  demonstrated  in  11.45  per  cent.  Several  times  masturbation  was  con- 
fessed, or  else  gonorrhea  with  orchitis,  or  syphilis,  had  preceded.  But.  in 
addition.  Kehrer  thinks  tliat  the  diseases  of  the  female  sexual  apparatus  that 
may  cause  sterility  arc  considered  too  lightly. 

*The  g'ynecf)lojiic  (-stimaU'  above  f|uritecl  is,  in  the  author's  opinion,  far 
.short  of  the  marlv. 

■^Considei'ing  the  pix-valence  of  masturlialion,  tliis  oli.sei'\ation  is  of  no 
special   valuf. 

—  105  — 


IMPOTENCE  AND   STERILITY 

Utero-vaginal  catarrh  under  certain  circumstances  leads  to 
sterility,  and  Kehrer  also  thinks  that  bacteria  may  exert  a  destructive 
influence  upon  the  ovule.  It  is  questionable  whether  these  bacteria 
produce  inflammation  of  the  mucous  membrane  or  only  find  in  the 
latter  suitable  conditions  for  further  development.  Noeggerath 
found  eight  sterile  marriages  in  a  series  of  fourteen  to  be  the  fault 
of  the  male.  Gross,  in  a  table  comprising  one  hundred  and  ninety- 
two  cases,  shows  that  the  male  was  deficient  in  one  out  of  every 
six. 

Sterility  in  the  male  may  be  due  to  any  of  the  following  condi- 
tions : 

(a)  Non-secretion  of  semen — aspermia  (defective  or  dis- 
eased testes). 

{h)     The  semen  may  not  contain  spermatozoa  —  azoospermia. 

(c)  The  spermatozoa  may  be  few  in  number,  motionless,  or 
their  movements  ephemeral  —  oligospertma.  This  may  be  due  to 
aberration  of  the  male  sex  hormone. 

{d)  Obstruction  to  the  passage  of  active  spermatozoa  to  the 
deep  urethra  and  seminal  vesicles. 

{e)  Obstruction  to  the  escape  of  semen  from  the  meatus  — 
as  in  stricture. 

(/)  Escape  of  the  semen  at  some  point  between  the  deep 
urethra  and  meatus,  thus  preventing  its  proper  deposition  in  the 
vagina  —  as  seen  in  hypospadias  and  extensive  urethral  fistula.  The 
Australian  aborigines  had  an  ingenious  custom  of  slitting  the  floor 
of  the  urethra  Gown  to  the  penoscrotal  angle  in  a  certain  proportion 
of  males,  thus  forming  an  artificial  hypospadias,  to  prevent  con- 
ception. 

{g)  The  vitiation  of  hormone  production  already  men- 
tioned. 

Cryptorchids,  in  whom  the  testes  are  not  only  retained,  but  also 
are  in  an  embryonal  and  imperfectly-developed  condition,  are  usu- 
ally, if  not  invariably,  sterile.  This  does  not  apply  to  monorchids. 
Cryptorchids  are,  however,  often  potent  to  a  high  degree.  A  cryptor- 
chid  gonorrheic  under  the  author's  care  is  sexually  extremely  vigor- 
ous. Individuals  from  whom  both  testicles  have  been  removed 
necessarily  are  sterile.  When  both  organs  have  sustained  serious 
injuries,    sterility    may    result,    either    from    destruction    of    the 

—  106  — 


JTi  C.  I-  -    .    -,  -'i  1^  o  ^ 


STERILITY  IN   THE   MALE  ^    -^Uit. ,-, 

secreting  structure  of  the  organs  or  from  traumatic  occlusion  of  the 
efferent  ducts.  The  semen  may  be  secreted  in  proper  quantity  and 
of  a  healthy  quality,  yet  it  may  be  prevented  in  some  manner  from 
reaching  the  mouths  of  the  ejaculatory  ducts.  This  condition  is 
more  frequent  than  generally  is  supposed,  it  being  difficult  of  detec- 
tion on  account  of  the  fact  that  impotence  is  not  necessarily 
associated  with  it,  the  sexual  orgasm  being  attended  by  the  ejacula- 
tion of  secretions  from  various  portions  of  the  sexual  tract  that 
collectively  resemble  semen,  and  which  under  normal  circumstances 
form  an  important  and  considerable  component  part  of  that  fluid. 

As  already  stated,  the  relation  of  gonorrhea  or  urethritis  to 
sterility  is  a  very  important  one.  Epididymitis  is  attended  by  the 
exudation  of  inflammatory  lymph  in  and  about  the  epididymis. 
This  may  be  speedily  absorbed,  or  may  become  organized  into 
connective  tissue  that  subsequently  contracts  and  completely  obliter- 
ates the  tubes  of  the  epididymis  —  a  condition  which  most  effectu- 
ally prevents  the  escape  of  semen  from  the  testis  into  the  vas 
deferens.  When  consulted  regarding  matrimonial  unfruitfulness 
the  physician  should  carefully  inquire  of  the  husband  as  to  a 
gonorrheal  history,  and  especially  as  to  the  occurrence  at  some 
previous  time  of  double  epididymitis.  The  explanation  of  the 
apparent  sterility  of  the  wife  may  not  be  satisfactorily  determined 
until  after  a  microscopic  examination  of  the  semen  of  the  husband 
has  been  made. 

A  low  grade  of  chronic  inflammation  of  one  or  both  epididymes 
may  occur  without  sufficient  pain  or  swelling  to  especially  attract 
the  patient's  attention,  hence  examination  may  reveal  thickened  and 
indurated  epididymes  in  the  absence  of  a  history  of  epididymitis.  It 
should  be  remembered  also,  that  the  ejaculatory  ducts,  vasa 
dcferentia,  or  vesicles,  may  be  infected,  with  resultant  occlusion, 
without  either  history  or  objective  symptoms  of  epididymal  involve- 
ment. 

Inflammation  —  orchitis  —  and  infection  with  subsequent 
atrophy  of  the  testes  proper  may  occur  from  various  causes  and 
produce  sterility  or  impotence  —  or  both.  Orchitis  secondary  to 
parotiditis  is  a  frequent  cause.  Any  syste:mic  infection  may  result 
similarly.  Thus  the  author  has  met  with  a  case  in  which  one 
testicle  was  lost  from  trauma  and  the  other  some  years  later  from 

—  107  — 


IMPOTENCE  AND   STERILITY 

some  unknown  infection.  In  another  case,  one  testis  was  atrophied 
from  infection  secondary  to  vaccination,  and  the  other  from  no 
apparent  cause  some  time  later.  This  and  the  preceding  rare  case 
are  oddly  suggestive  of  a  similarity  to  the  so-called  sympathetic 
ophthalmia  in  which  one  eye  is  destroyed  by  one  cause  or  another — 
notably  by  foreign  bodies — and  the  remaining  eye  subsequently  is 
lost  without  immediate  exciting  cause,  after  an  interval,  perhaps, 
of  some  months  or  even  years.  The  author  recently  had  under 
observation  an  operative  case  of  his  own  in  which  unilateral  orchitis 
with  loss  of  the  testicle  followed  a  few  weeks  after  supra-pubic 
section  for  removal  of  vesical  carcinoma. 

The  imminent  danger  of  atrophy  and  loss  of  function  of  the 
testis  from  true  orchitis,  suggests  the  imperative  duty  of  operative 
relief  of  tension  in  all  cases,  even  of  the  traumatic  variety.  The 
old  idea  that  a  hematoma  of  the  testis  or  cord  should  not  be  operated, 
is,  in  the  author's  opinion,  responsible  for  numerous  cases  of  testicle 
destruction. 

Injuries  to  the  prostatic  urethra  incident  to  operations  upon 
urethral  stricture  or  stone  in  the  bladder  may  produce  occlusion  of 
the  mouths  of  the  ejaculatory  ducts  and  consequent  sterility. 
Cauterization  of  the  prostatic  sinus  may  result  in  a  similar  condi- 
tion. A  well-known  French  writer  observed,  regarding  the  use  of 
the  portc-causiique  by  Lallemand,  that  by  its  use  many  men  had  been 
unsexed,  causing  "more  eunuchs  than  had  all  the  harems  of  the 
east."  It  is  to  be  remembered  that  sterility  in  the  male  may  be 
attended  by  absolutely  no  symptoms  that  will  lead  to  a  satisfactory 
diagnosis  without  resort  to  the  microscope.  Both  seminal  ducts 
may  be  occluded,  so  that  the  semen  cannot  by  any  possibility  pass 
through  the  ejaculatory  ducts,  yet,  if  the  testes  are  well  developed 
and  firm  and  in  a  perfectly  normal  condition,  sexual  desire,  power 
of  erection  and  pleasurable  sensations  are  normal.  When  these 
phenomena  are  normal,  yet  spermatozoa  are  not  emitted,  it  usuallv 
is  safe  to  infer  that  there  is  mechanic  obstruction  to  the  escape  of 
semen  from  the  testes,  rather  than  a  secretory  ])erturbation,  even 
though  these  organs  and  their  ducts  i)rescnt  no  evidences  of  disease. 

The  gross  uppenrancc  of  the  fluid  ejaculated  during  the  sexual 
orgasm  in  a/()(">sperniia  may  be  almost  precisely  similar  in  ap])ear- 
ance  to  normal  semen,  the  absence  of  spermatozoa  alone  constituting 

—  108  — 


STERILITY   IN   THE   MALE 

its  principal  clinical  feature.  As  a  rule,  however,  the  fluid  is  thin 
and  watery. 

Men  who  are  suffering  from  pronounced  stricture  of  the  urethra 
are  likely  to  be  sterile,  as  a  consequence  of  interference  with  ejacula- 
tion of  the  semen.  In  cases  of  stricture  of  long  duration,  sterility 
may  persist  for  some  time  after  the  urethral  obstruction  has  been 
removed.  This  is  due  to  the  fact  that  the  obstruction  to  ejacu- 
lation has  resulted  in  the  semen  being  habitually  forced  back- 
ward into  the  bladder  past  the  vent  montanitm,  or  colUculus  scmi- 
nalis,  the  function  of  which  is  to  prevent  such  backward  passage 
under  ordinary  pressure  and  to  facilitate  the  extrusion  of  the  sper- 
matic fluid  from  the  urethra.  It  is  said  that  there  exists  in  Paris  a 
certain  class  of  prostitutes  who  prevent  concej^tion  by  passing  the 
index  finger  into  the  rectum  of  the  male  during  intercourse,  and 
pressing  upon  the  membranous  urethra  just  in  front  of  the  prostate 
at  the  moment  of  ejaculation.  This  ingenious  and  disgusting  prac- 
tice causes  the  semen  to  be  forced  back  into  the  male  bladder  by 
overcoming  the  resistance  of  the  colUculus.  If  this  performance  be 
indulged  in  frequently,  the  function  of  this  erectile  structure  may  be 
permanently  destroyed,  the  individual  ever  after  ejaculating  his 
semen  into  his  own  bladder.  In  most  cases  of  pronounced  stricture 
the  semen  is  retained  in  the  urethra  until  erection  subsides,  when  it 
slowly  dribbles  away.  In  hypospadias  and  epispadias  the  deformity 
of  the  urethra  may  be  such  as  to  prevent  the  extrusion  of  the  semen 
far  enough  into  the  vagina  to  accomplish  impregnation.  Individuals 
thus  affected  practically  are  sterile. 

A  further  and  excellent  illustration  of  potency  conjoined  with 
sterility  is  a  case  that  the  author  elsewhere  has  described  as  illustra- 
tive of  the  effects  of  pathologic  changes  in  the  epididymis.  A 
tuberculous  testicle  was  removed  from  this  patient,  and  in  a  few 
months  chronic  inflammation  and  induration  occurred  in  the  remain- 
ing organ.  As  a  consequence,  while  the  patient  found  that  his  sexual 
desire  and  power  were  very  much  stronger  than  prior  to  the  opera- 
tion, he  stated  that  after  the  appearance  of  disease  in  the  remaining 
organ  he  no  longer  had  emissions,  the  orgasm  being  apparently 
perfectly  normal  with  the  exception  of  the  absence  of  seminal  dis- 
charge. 

It  sometimes  is  very  difficult  accurately  to  determine  the  causes 
of  a  lack  of  fecundating  power  in  the  semen.     Thus,  the  sperma- 

—  109  — 


IMPOTENCE  AND   STERILITY 

tozoa  may  be  absent  from  the  seminal  fluid  in  cases  in  which  there  is 
no  history  of  inflammatory  trouble  with  the  testicle  or  other  causes 
that  would  prevent  its  formation  or  discharge. 

In  some  instances,  probably  from  constitutional  depression  or 
cachexia,  the  elaborated  semen  is  perverted  in  quality  and  deficient 
in  quantity,  the  vitalizing  element  being  either  absent  entirely  or  of 
such  degenerate  constitution  that  it  is  incapable  of  impregnating  the 
ovule.  Spermatozoa  may  be  present  at  one  time,  and  absent  at 
another  in  certain  instances,  according  to  the  constitutional  condition 
of  the  patient  at  the  time.  In  one  case  of  a  professional  man  of  the 
author's  acquaintance,  sterility  had  existed  for  a  number  of  years ; 
the  semen,  being  examined  at  various  times,  was  found  to  contain 
no  spermatozoa,  yet  they  finally  appeared  in  the  seminal  discharge 
and  the  patient  succeeded  in  impregnating  his  wife. 

In  connection  with  the  subject  of  sterility  the  varying  vitality  of 
both  ovule  and  spermatozoa  must  be  taken  into  consideration.  As  is 
well  known,  there  is  no  constant  relation  between  the  performance 
of  the  sexual  act  and  the  discharge  of  the  ovule.  It  therefore  is 
necessary,  in  order  that  impregnation  may  be  facilitated,  that  both 
the  male  and  the  female  elements  be  capable  of  retaining  their 
vitality  for  a  certain  length  of  time.  Obviously,  if  this  were  not  the 
case,  it  would  be  necessary  for  copulation  and  ovulation  to  occur 
simultaneously.  By  a  wise  provision  of  nature,  however,  both 
ovule  and  spermatozoa  retain  their  vitality  for  a  considerable  time. 
It  has  been  claimed  by  some  physiologists  that  their  vitality  is  pre- 
served for  a  week  or  ten  days,  or  even  longer.  If,  during  the  persist- 
ence of  this  vitality,  the  male  and  female  elements  are  brought  in 
contact,  impregnation  is  likely  to  occur.  Anything  that  lessens  the 
period  during  which  the  elements  necessary  to  conception  retain 
their  vitality  tends  to  produce  sterility.  In  some  females  it  is  neces- 
sary for  copulation  to  take  place  either  just  before  or  shortly  after 
menstruation,  in  order  that  conception  may  occur.  The  mid-period 
necessarily  is  least  favorable  to  conception,  for  at  this  time  the  ovule 
has  reached  its  minimum  degree  of  vitality,  if,  indeed,  it  has  not 
already  become  disintegrated.  Between  this  period  and  the  next 
ovulation  a  sufficient  time  will  have  elapsed  to  impair,  or  perhaps 
destroy,  the  vitality  of  the  spermatozoa.  The  sources  of  fallacy 
in  taking  this  fact  as  a  basis  for  precautions  against  pregnancy  are 
the  varying  vitality  of  the  ovule  and  spermatozoa  and  the  fact  that 

—  110  — 


STERILITY   IX   THE   MALE 

ovulation  probably  is  not  necessarily  coincident  with  menstruation. 
Indeed,  ovulation  probably  may  occur  at  the  time  of  the  sexual  act 
as  a  result  of  extreme  sexual  excitement.  These  physiologic  facts 
are  worthy  of  consideration  in  the  management  of  some  cases  of 
sterility.  For  example,  if  copulation  be  permitted  only  just  before 
and  after  menstruation,  the  sexual  energies  of  both  parties  to  the 
act  are  conserved  and  made  more  active.  The  se^fual  passion  is 
stronger  in  the  female  at  this  time,  and,  if  the  male  is  abstinent  at 
other  times,  he,  too,  is  likely  to  be  more  passionate  and  vigorous. 
By  taking  this  precaution  the  ovum  and  spermatozoa  will  be  brought 
in  contact  at  the  time  when  the  vitality  of  both  is  at  its  maximum. 

Leaving  the  question  of  impotence  out  of  consideration,  it  is  a 
well-known  fact  that  sterile  marriages  occasionally  are  observed 
where  both  husband  and  wife  are  perfectly  capable  of  procreation, 
yet  for  some  peculiar  reason  the  elements  necessary  for  conception 
apparently  have  no  affinity  for  each  other,  and  this  independently 
of  the  question  of  sexual  passion.  The  truth  of  this  assertion  is 
shown  by  the  fact  that  in  many  instances  individuals  who  have  been 
childless  in  a  first  marriage  have  married  again,  and  have  reared 
large  families.  The  physiologic  question  involved  under  these  cir- 
cumstances is  well  recognized  by  stock-breeders,  who  find,  for 
example,  that  certain  mares  cannot  be  fecundated  by  a  stallion  that 
perhaps  is  distinguished  by  the  multiplicity  of  his  progeny,  but  are 
readily  impregnated  when  covered  by  another  and  even  inferior 
stallion. 

It  is  conceivable  that  varying  states  of  vitality  of  the  sperma- 
tozoa may  result  from  morbid  conditions  affecting  the  general  health. 
Perfection  of  elaboration  of  the  various  secretions  of  the  body 
depends  greatly  on  the  condition  of  the  individual.  It  is  well  known 
that  the  secretions  of  the  salivary,  mammary,  and  gastro-intestinal 
glands  are  greatly  modified  by  mental  emotions,  and  by  various 
pathologic  conditions  affecting  the  system  at  large,  and  why  may 
not  this  be  equally  true  as  regards  the  semen?  It  is  probable  that 
the  condition  of  the  emotional  faculties  at  the  time  of  copulation 
have  much  to  do  with  fertility  in  the  human  subject.  This  is  one 
of  the  possible  explanations  of  the  infrequency  of  conceptions  in 
prostitutes,  in  whom,  however,  the  results  of  infection  usually  sooner 
or  later  are  an  all-sufficient  explanation. 

Abuse  of  the  sexual  apparatus,  either  through  masturbation  or 

—  Ill  — 


IMPOTENCE  AND   STERILITY 

sexual  excess,  next  to  inflammatory  troubles  of  the  testicle  is  prob- 
ably the  most  frequent  cause  of  sterility.  Prolonged  overstimulation 
of  the  secreting  structures  of  the  testes  finally  results  in  exhaustion 
and  relaxation  of  the  organs,  the  semen  being  imperfectly  elaborated, 
even  though  its  quantity  and  consistency  may  be  apparently  the 
same.  Again,  the  frequent  shocks  to  the  nervous  system  involved 
in  the  oft-recurring  orgasm,  in  combination  with  the  drain  afforded 
by  the  excessive  loss  of  seminal  secretion,  results  in  constitutional 
debility ;  and  this  again,  reacting  upon  the  semen,  devitalizes  it. 
The  important  relation  that  the  bodily  condition  bears  to  the  number 
and  constitution  of  the  spermatozoids  can  hardly  be  overestimated. 
Other  things  being  equal,  the  activity  and  potency  of  the  spermatic 
cells  is  in  direct  proportion  to  the  strength  and  vigor  of  the  general 
system. 

The  author's  theory  of  the  physiologic  relation  of  the  supply  and 
constitution  of  the  sex  hormone  to  the  procreative  act,  and  therefore 
to  both  sterility  and  impotence,  will  receive  special  attention  later  on. 

Diagnosis. — The  diagnosis  of  sterility  in  the  male  can  be  made 
only  by  examination  of  the  ejaculated  discharge.  When  the  sper- 
matozoids are  found  to  be  absent,  feeble,  imperfectly  formed,  or 
few  in  number,  the  source  of  the  infecundity  of  the  individual  is  at 
once  apparent.  Defective  hormone  supply  may  in  part  explain  such 
conditions.  Careful  physical  examination  of  the  testicles  and  sper- 
matic cords,  with  exploration  of  the  urethra,  may  demonstrate  the 
fact  that  the  trouble  is  not  defective  elaboration  of  semen,  but 
obstructive,  the  semen  being  prevented  from  escaping  into  or  from 
the  urethra.  This  is  the  only  logical  inference  if  the  testes  are  firm 
and  hard  and  of  the  proper  size,  the  spermatic  cords  being  also 
apparently  healthy.  Relative  sterility,  due  to  hormone  perversion 
or  incompatibility,  with  numerous  and  active  spermatozoa,  neces- 
sarily is  too  occult  for  detection. 

Prophylaxis  of  sterility  in  both  sexes  largely  consists  in 
careful  treatment  of  gonorrhea  and  its  complications.  It  is  obvious 
that  successful  treatment  in  the  male  in  a  large  measure  protects 
both  sexes  from  sterility.  Competence  and  thoroughness  on  the 
part  of  the  genito-urinary  surgeon  stands  between  the  public  and 
much  sterility.  Not  the  least  of  his  functions  is  to  prevent,  if 
possible,  uncured  gonorrheics  from  marrying.  The  management  of 
epididymitis  is  especially  important  in  its  bearing  on  possible  sterility 

—  112  — 


PROPHYLAXIS    OF    STERILITY 

in  the  male.  After  critical  observation  and  experience  extending 
over  a  ])eriod  of  some  nine  years — following  Hagner's  work  in 
epididymotomy  in  1906 — the  author  has  arrived  at  the  conclusion 
that  e])ididymitis  invariably  should  be  treated  by  radical  operative 
measures.  Although  the  surgery  of  acute  inflammation  of  the 
epididymis  is  not  new,  the  disease  almost  universally  has  been 
"mollycoddled."  Physician  and  patient  alike  have  failed  to  com- 
])rehend  the  seriousness  of  the  condition  as  regards  its  menace  to 
the  comfort,  efficiency  and  especially  the  fertility  of  the  affected 
individual. 

Following  epididymitis  in  the  large  majority  of  cases  t^e  testis 
of  the  affected  side  is  "put  out  of  business."  i.  c,  while  still  poten- 
tially fertile,  it  is  dynamically  sterile  by  virtue  of  permanent  occlu- 
sion of  the  infected  and  inflamed  epididymis  or  vas,  or  both.  In 
that  rare  condition,  simultaneously  double  epididymitis,  or  that 
frequent  accident,  an  epididymitis  subsequently  occurring  upon  the 
opposite  side.     Sixty-five  per  cent,  of  the  subjects  are  made  sterile. 

Aside  from  the  danger  of  sterility,  recurrent  epididymitis  and 
reinfection  of  the  posterior  urethra  from  an  infective  focus  remain- 
ing in  the  epididymis  often  are  a  source  of  serious  crippling.  Then, 
too.  the  probability  of  certain  obscure  cases  of  rheumatism  being 
due  to  latent  infection  in  the  epididymis  is  worthy  of  consideration. 
It  also  will  be  noted  that  the  analogy  between  pus  tubes  and  the 
infected  epididymis  is  by  no  means  far  fetched. 

In  considering  the  surgical  aspects  of  epididymitis  the  character 
of  the  infection  is  of  no  moment  —  excluding,  of  course,  the  tuber- 
cular form.  Gonococcus,  colon  bacillus  and  staphylococcus  are  alike, 
so  far  as  the  surgical  management  of  the  inflamed  epididymis  is 
concerned.     The  benefits  of  epididymotomy  are  due  to 

1st.     Relief  of  tension. 

2nd.    Depletion. 

3rd.    Drainage. 

It  is  the  author's  opinion  that  the  tension  of  the  epididymal 
walls  is  accountable  in  a  measure  for  permanent  occlusion  of  the 
tubuli.  The  acute  tension  due  to  the  thickening  of  the  epididymis 
and  more  or  less  internal  exudate,  impairs  the  integrity  of  the 
tubular  structures  as  well  as  occludes  them.  When  closely  pressed 
together  the  tubuli  are  more  likely  to  become  distorted,  kinked  and 

—  113  — 


IMPOTENCE  AND   STERILITY 

glued  shut,  than  when  there  is  no  abnormal  pressure  from  within 
and  without  the  epididymis.  Here,  then,  is  the  cue  for  prevention 
of  a  large  number  of  cases  of  sterility  in  the  male :  Relieve  tension 
in  the  epididymitis  by  multiple  incisions  or  punctures  of  the  dense 
zvalls  of  the  affected  part. 

Treatment. — The  treatment  of  sterility  in  the  male  unfor- 
tunately is  unsuccessful  in  a  large  proportion  of  cases.  Chronic 
inflammatory  conditions  of  the  epididymis  sometimes  may  be  re- 
moved by  measures  that  will  be  suggested  later  in  the  consideration 
of  diseases  of  the  testicle.  Electricity  is  perhaps  the  most  rehable 
remedy  at  our  command  for  these  conditions.  Tonics,  proper  food, 
and  attention  to  sexual  hygiene  occasionally  may  accomplish  the 
desired  result.  It  must  be  confessed  that  there  are  many  cases  in 
which,  however  faithfully  we  may  seek  for  the  cause  of  sterihty, 
it  escapes  observation,  and  the  case  consequently  is  absolutely  in- 
curable. Some  of  the  conditions  that  obstruct  the  passage  of  the 
semen  from  the  urethra  may  be  removed,  stricture  being  the  morbid 
state  that  is  especially  amenable  to  treatment. 

Obstructions  in  the  vas  sometimes  are  removable  by  resection 
followed  by  the  author's  method  of  anastomosis.  When  they  are 
close  to  the  epididymis  and  both  vasa  defer entia  are  involved,  the 
vas  may  be  anastomosed  with  the  epididymis  as  suggested  by 
Edward  Martin.  This  operation  as  described  by  its  originator  is  as 
follows : 

"The  vas  lies  behind  the  spermatic  artery,  which  sends  its 
main  branches  forward  to  the  inner  side  of  the  epididymis,  anasto- 
mosing freely  at  this  point  with  the  artery  of  the  vas.  The  epidid- 
ymis is  approached  from  its  outer  side.  A  portion  of  the  head  is 
picked  up  in  toothed  forceps  and  excised.  If  the  excision  is  made 
on  the  testicular  side  of  the  obstruction  there  will  ooze  from  the 
wound  semen  which  contains  motile  spermatozoa.  The  lumen  of 
the  vas  is  opened  by  a  longitudinal  cut  one-quarter  of  an  inch  long. 
Into  the  wound  of  the  epididymis  the  vas  is  implanted  by  means 
of  four  fine  silver-wire  sutures,  carried  on  small  face  needles  from 
the  outer  surface  of  the  vas  into  its  lumen ;  thence  from  the  cut 
surface  of  the  opening  made  into  the  epididymis  through  its  fibrous 
tunic.  Because  of  the  smallncss  of  the  structures  involved,  the 
operation  is  tedious  rather  than  difficult.     Aside  from  the  ordinary 

—  114  -  - 


TREATMENT   OF   STERILITY   IN   THE   MALE 

surgical  instruments,  there  will  be  needed  a  sharp-pointed  pair  of 
scissors,  a  slender  bistoury  and  a  grooved  director,  such  as  are  used 
by  ophthalmologists." 

Lespinasse  has  ingeniously  suggested  the  formation  of  an  arti- 
ficial sac  or  reservoir  for  the  semen  in  connection  with  the  epidid- 
ymis in  obseructive  sterility  in  the  male.*  The  semen  is  to  be 
withdrawn  by  aspiration  from  the  husband  as  required  and  injected 
into  the  uterus  of  the  wife. 

Although  not  potentially  sterile,  hypospadiacs  and  subjects  with 
urethral  fistula  may  be  dynamically  sterile  because  the  semen  is  not 
discharged  so  that  it  reaches  the  vicinity  of  the  cervix.  These  cases 
may  be  curable  by  operation.  Disproportionate  size  of  the  penis 
sometimes  is  a  cause  of  sterility.  This  condition  is  hopeless.  Arti- 
ficial fecundation  is  the  only  recourse. 

Sterility  is  sometimes  due  to  syphilis  which  may  produce 
chronic  inflammation,  although  gross  lesions  are  not  perceptible. 

Sterility  due  to  syphilis  sometimes  is  curable  by  the  ordinary 
therapevitic  routine. 

Conformably  with  his  views  of  the  intimate  relation  of  the 
proper  formation  of  sex  hormone  to  fertility,  the  author  believes 
that  his  method  of  sex  gland  implantation  may  have  a  considerable 
range  of  usefulness  in  both  sexes  as  a  remedy  for  sterility.  This 
subject  later  will  be  more  fully  discussed. 

Impotenck   IX    THE    Male. 

In  the  majority  of  cases  of  impotence  there  apparently  is  a 
normal,  or,  at  most,  merely  a  debilitated  and  flaccid  condition  of 
the  generative  apparatus,  yet  the  patient  is  unable  to  obtain  an 
erection.  The  lack  of  power  varies  in  degree  from  a  condition  in 
which  there  is  absolutely  no  manifestation  of  the  physiologic 
function  of  erection  to  cases  in  which  the  erection  is  partial,  but 
insufficient  for  copulation.  In  some  instances  erection  is  perfect, 
but  of  a  transitory  character,  ejaculation  occurring  prematurely. 
Care  should  be  taken  to  dififerentiate  the  cases,  else  treatment  is  not 
likely  to  be  successful.  Clinically  it  will  be  found  that  cases  of 
impotence  may  be  divided  into : — 

1.     Those  in  which  virility  is  impaired  by  general  constitutional 

•  Trans.   American   Urological   Assoc,    1914. 

—  115  — 


lmpotkncp:  and  sterility 

debility  or  exhaustion  of  nervous  force  —  impairment  of  hormone 
supply  being  one  element  —  the  lack  of  sexual  vigor  being  functional 
and  secondary  to  the  general  disturbance.  These  cases  may  depend 
upon :  a.  sexual  excess  or  masturbation,  which  produce  both  local 
and  general  debility,  or  /;.  general  diseases  of  an  exhausting  char- 
acter, c.  Profound  psychic  impressions,  d.  Shock  from  trauma. 
They  may  or  may  not  be  associated  with  spermatorrhea,  nocturnal 
emissions,  etc. 

2.  Cases  in  which  the  lack  of  power  is  entirely  due  to  adverse 
psychic  impressions. 

3.  Those  in  which  the  patient  is  strong  and  vigorous,  his  testes 
secreting  actively,  and  his  vesicnlcc  seminales  being  overdistended  as 
a  consequence  of  infrequent  indulgence.  In  these  cases  premature 
ejaculation  and  a  transitory  character  of  erection  are  the  principal 
features. 

4.  Those  in  which,  as  a  consequence  of  masturbation  or  sexual 
excess,  there  is  hyperesthesia  of  the  floor  of  the  prostatic  urethra, 
or  colliculitis.  Imperfect  secretion  and  premature  ejaculation  char- 
acterize these  cases. 

5.  Cases  in  which  there  is  some  pathologic  condition  of  the 
sexual  apparatus  that  acts  by  distvu^bing  innervation  and  producing 
mental  depression,  chiefly  from  the  moral  efifect  of  the  condition. 

6.  Those  in  which  deformity  or  acquired  disease  interferes 
with  erection,  completely  or  partially  preventing  it. 

7.  Those  in  which  congenital  malformations,  injury,  disease, 
or  surgical  operation  have  impaired  or  destroyed  the  structure  of 
the  sexual  apparatus  to  an  extent  sufficient  to  prevent  copulation. 

8.  Cases  due  to  toxemia — from  disease  or  from  alcoholics  or 
other  drugs. 

Some  of  these  conditions  are  amenable  to  treatment,  while 
others,  unfortunately,  are  beyond  the  reach  of  medical  art. 

Impotence  is  divided  for  description  into  the  false  and  true 
varieties. 

PsivUDO-iMPOTivNCK. — False  impotence  is  the  form  that  is  most 
frequently  seen,  and  usually  is  dependent  upon  causes  of  a  purely 
mental  or  moral  character,  the  sexual  organs,  so  far  as  can  be 
determined  by  examination,  being  perfectly  healthy.  Individuals 
suffering  from  this  form  of  impotence  usually  are  of  a  highly  im- 
pressionable  nervous   temperament   primarily,   or  have   become   so 

—  116  — 


IMPOTENCE   IN   THE   MALE 

as  a  consequence  of  masturbation  or  sexual  excesses.  Some  men 
who  apparently  are  perfectly  healthy  find  themselves  unable  to 
perform  the  act  of  copulation  as  a  consequence  of  a  lack  of  con- 
fidence due  to  a  recollection  of  early  indiscretions  and  an  exaggerated 
estimate  of  their  effects.  Ignorance  of  sexual  physiology  often  is 
the  foundation  for  this  form  of  im])otence.  Failure  to  accomplish 
the  act  of  sexual  intercourse  sometimes  is  due  —  paradoxic  as  it 
may  seem  —  to  extraordinary  vigor  and  secretory  activity  of  the 
sexual  apparatus.  Individuals  who  have  masturbated  but  little,  or 
perhaps  not  at  all,  and  who  never  have  attempted  sexual  inter- 
course until  they  have  attained  their  majority,  frequently  are 
troubled  in  this  manner.  The  author  recalls  several  cases  of  this 
kind : — 

Cask. — A  j-oung  professional  man  30  years  of  age,  a  fine  healthy-ap- 
pearing subject  as  could  be  imagined.  He  had  masturbated  but  little  as  a  boy, 
and  after  attaining  adult  age  became  very  fond  of  the  society  of  women  and 
acquired  the  reputation  of  being  something  of  a  i-ouc,  yet  he  assured  the 
author  that  he  never  had  been  able  to  accomplish  the  act  of  copulation,  pre- 
mature ejaculation  having  attended  every  attempt — such  attempts  having 
been  made  at  very  infrequent  intervals.  He  seemed  to  think  that  there  was 
some  organic  disease,  either  of  the  sexual  organs  or  "of  the  blood,"  that 
inhibited  his  sexual  pcnvers.  Examination  showed  that  the  sexual  organs 
were  perfectly  healthy.  On  careful  interrogation  he  said  that  he  never  had 
attempted  intercourse  twice  consecutively,  but  had  Iiecome  thoroughly  dis- 
gusted by  his  first  failure  on  each  occasion.  It  seemed  that  intercourse  al- 
ways had  been  attempted  under  circumstances  involving  not  only  extreme 
sexual  excitement,  but  more  or  less  uneasiness  as  regards  the  possibility  of 
detection.  All  possible  means  were  tried  to  convince  this  patient  that  he 
was  perfectly  sound  and  sexually  potent,  but  without  result.  He  still  enter- 
tains the  opinion  that  he  is  impotent,  and  nothing  but  success  in  copulation, 
which  certainly  will  be  achieved  if  the  act  is  ever  attempted  under  proper 
circumstances,  ever  will  convince  him  to  the  contrary.  Overdistension  of 
the  seminal  vesicles,  in  combination  with  overexcitement  and  consequent 
hyperesthesia  of  the  prostatic  sinus  existing  at  the  time  of  attempted  copula- 
tion, is  the  explanation  of  tlie  pseudo-impotence  of  this  individual. 

Cask. — .\  similar  case  that  came  under  our  observation  was  much  more 
tractable.  This  patient  stated  that  he  never  had  masturbated  and  never  had 
attempted  intercourse  until  past  the  age  of  25.  fie  was  of  an  exceedingly 
passionate  temperament,  and  has  found  that  he  never  had  been  able  to  ac- 
complish the  act  at  a  first  or  even  a  second  attempt,  but  that  if  he  attempted 
the  act  repeatedly  with  a  person  with  whom  he  had  the  opportunity  of  as- 
sociating for  several  days  at  a  time,  he  finally  succeeded,  and  thereafter  was 
in  a  perfectly  normal  condition.     He  finally  happily  married  and  has  several 

—   117  — 


IMPOTENCE  AND   STERILITY 

children.     The  persistency  of  this  individual  is  all  that  saved  him  from  the 
same  despairing  frame  of  mind  as  that  which  exists  in  the  previous  case. 

The  form  of  impotence  born  of  excessive  and  uncontrolled 
desire  has  been  familiar  from  time  immemorial.  Three  centuries 
ago  Montaigne  dilated  upon  it  in  his  philosophic  essays  as  follows : — 

Neither  is  it  in  the  height  and  greatest  fury  of  the  fit  that  we  are  in 
a  condition  ...  to  sally  into  courtship,  the  soul  being  at  that  time  over- 
burthened  and  laboring  with  profound  thoughts,  and  the  body  dejected  and 
languishing  with  desire ;  and  hence  it  is  that  sometimes  proceed  those  acci- 
dental impotencies  that  so  unreasonably  surprise  the  willing  lover,  and  that 
frigidity  which  by  the  force  of  an  immoderate  ardor  so  unhappily  seizes  him 
in  the  very  lap  of  fruition ;  for  all  passions  that  suffer  themselves  to  be 
relished  and  digested  are  but  moderate. 

The  surgeon  not  infrequently  is  called  upon  for  relief  for  just 
such  impotencies  as  Montaigne  so  clearly  describes.  That  the 
remedy  is  better  psychic  control  goes  without  saying. 

Continence  as  a  cause  of  true  impotence  has  been  admitted  by 
some  writers.  Howe  relates  two  interesting  cases  that  apparently 
were  due  to  this  cause : — 

Case  1. — In  the  winter  of  1876  an  undertaker  of  this  city  was  ad- 
mitted to  St.  Francis  Hospital,  suffering  from  prolapse  of  the  rectum.  He 
was  45  years  old  and  his  general  health  was  good.  After  recovering  from  the 
prolapse  he  informed  me  that  he  was  impotent,  and  likewise  was  subject  to 
nocturnal  emissions.  During  the  whole  course  of  his  life  he  had  refrained 
from  any  gratification  of  his  passions,  and  had  never  attempted  sexual  in- 
tercourse until  within  the  past  year.  Twelve  months  previous  to  his  ad- 
mission he  had  m.arried,  and  without  expecting  anything  of  the  kind  found 
himself  impotent  and  unable  to  consummate  the  marriage.  Every  attempt 
at  intromission  failed,  through  weak  erections  and  rapid  emissions.  He 
denied  masturbation,  and  the  condition  of  the  genitals  seemed  to  confirm  his 
statement.  From  the  age  of  25  he  had  emissions  once  a  fortnight  and  fre- 
quent erections,  but  the  erections  were  feeble,  and  lasted  only  a  few 
moments.  Since  his  marriage  the  emissions  had  increased  in  frequency, 
and  there  seemed  to  be  much  relaxation  and  apparent  elongation  of  the 
penis.  The  patient  did  not  seem  to  be  depressed  by  the  fact  of  his  impotence. 
He  attributed  it  all  to  total  abstinence,  and  hoped  that,  in  the  course  of  time, 
Nature  would  effect  a  cure. 

The  author  does  not  believe  that  continence  per  se  ever  causes 
true  impotence.  The  cases  in  which  it  apparently  does  so  usually 
are  either  masturbators  or  congenitally  weak,  or  both. 

A  few  cases  are  recorded  by  Lallemand  and  others  where  rectal 
disease  caused  temporary  impotence,  but  the  patients  were  not  con- 

—  118  — 


IMPOTENCE   IN   THE   MALE 

tinent,  and  they  recovered  from  the  spermatorrhea  and  impotence 
when  the  prolapse  was  cured.  In  the  patient  whose  history  has 
just  been  given  the  prolapse  of  the  rectum  may  have  added  to  the 
genital  weakness,  but  it  probably  was  not  the  cause  of  it. 

Howe   records   a   second   interesting  case   of   impotence    from 
continence,  unaccompanied  by  spermatorrhea : — 

Case  2. — The  patient  was  38  years  old,  and  a  broker  by  occupation. 
His  general  health  was  excellent,  and  he  was  constantly  and  actively  em- 
ployed in  a  flourishing  business.  He  commenced  to  masturbate  a  little  when 
a  boy  of  12,  and  occasionally  was  guilty  of  the  habit  until  he  reached  the 
age  of  16,  at  which  time  he  discontinued  it  altogether.  At  twenty  he  had 
intercourse  in  a  natural  way,  and  without  any  difficulty  whatever.  For  six 
months  subsequently  he  cohabited  at  intervals  of  two  weeks,  and  never  at 
any  time  indulged  to  excess.  A  period  of  eight  years  then  elapsed  without 
any  opportunity  for  sexual  congress.  At  the  termination  of  that  period  he 
again  attempted  to  renew  his  sexual  relations  with  his  former  partner,  but, 
to  his  great  annoyance,  failed.  Though  he  subsequently  made  frequent  trials, 
the  result  was  the  same.  He  finally  gave  up  all  hope,  firmly  believing  that 
his  impotence  was  beyond  the  reach  of  therapeutic  agents.  He  attributed 
his  loss  of  virility  to  continence,  and  not  to  any  dissipation  or  bad  habits 
in  early  life.  A  period  of  ten  years  elapsed,  during  which  interval  he  tried 
sexual  congress  but  once,  and  was  unsuccessful.  He  had  few  emissions,  and 
few  erections.  For  twelve  months  previous  to  calling  at  my  office  he  had 
had  only  three  emissions,  and  no  erections  of  any  degree  of  permanence. 
He  thought  his  desire  for  sexual  pleasures  had  not  diminished,  but,  the 
knowledge  of  his  impotence  being  ever  present,  would  prevent  him  from  at- 
tempting it  again.  This  mental  state  necessarily  complicated  his  case,  and 
added  to  the  difficulty  of  a  cure.  On  making  an  examination  of  his  genital 
organs  I  found  the  penis  and  testicles  somewhat  smaller  than  natural.  The 
left  testicle  was  smaller  than  the  right,  and  more  than  ordinarily  sensitive 
to  pressure.  Otherwise  the  parts  were  unchanged.  Knowing  that  the 
patient's  habits  were  excellent,  and  that  his  general  health  was  good,  I  made 
a  favorable  prognosis,  and  put  him  under  treatment.  He  continued  under 
treatment  for  three  months,  improving  slowly.  His  erections  were  more  fre- 
quent and  natural,  and  his  hopes  of  final  recovery  revived.  He  suddenly, 
without  any  notification,  ceased  his  visits  at  the  office.  The  summer  follow- 
ing he  consulted  me  for  gonorrhea,  and  informed  me  that  a  few  days  after 
he  had  ceased  calling  he  renewed  his  attempt  at  intercourse,  and  suc- 
ceeded, and  had  kept  well   in  that  respect  ever  since. 

The  author  has  seen  so  many  cases  similar  to  those  reported  by 
Howe,  that  he  feels  warranted  in  the  belief  that  prolonged  continence 
in  exceptional  cases  bears  a  definite  etiologic  relation  to  impotence. 
As  already  stated,  however,  he  does  not  believe  that  continence 
alone  ever  causes  true  impotence.     Oftentimes  the  impotence  is 

—  119  — 


IMPOTENCE  AND   STERILITY 

purely  psychic,  resulting  from  the  fear  of  non-success.  The  patient's 
confidence  sometimes  is  shaken  by  the  popular  notion  that  prolonged 
continence  necessarily  results  disastrously.  In  some  cases  the 
patient's  statements  regarding  masturbation  should  be  discounted. 
It  is  nothing  unusual  for  patients  to  assert  that  they  have  practiced 
the  vice  "but  a  few  times,"  etc.,  when,  as  a  matter  of  fact,  they  not 
only  have  practiced  it  very  frequently,  but  are  not  yet  rid  of  the 
habit.  In  a  general  way,  however,  men  who  abstain  from  sexual 
intercourse  up  to  thirty  years  of  age  often  are  impaired  in  their 
sexual  power  —  pseudo-impotence  —  even  though  they  have  not 
masturbated.  Disuse  is  detrimental  to  the  vigor  of  all  organs,  and  it  is 
not  surprising  that  a  certain  degree  of  inhibition  of  sexual  activity 
should  result  in  such  cases.  Where  they  have  masturbated,  especially 
if  the  habit  has  not  been  broken,  impotence  is  common.  When  men 
of  thirty  or  over  deny  both  masturbation  and  normal  sexual  indul- 
gence, a  primary  lack  of  sexual  activity  may  be  suspected.  On  the 
other  hand,  sexual  repression  continued  for  years  may  seriously 
inhibit  primarily  active  sexual  impulses. 

It  should  be  remembered,  in  considering  the  subject  of  pseudo- 
impotence,  that  the  sexual  passion  varies  in  intensity  in  different 
individuals.  Many  persons  are  of  frigid  temperament  and  are  likely 
to  exhibit  more  or  less  sexual  indifference.  This  usually  is  associated 
with  a  relative  sluggishness  of  the  sexual  apparatus,  which,  however, 
is  perfectly  natural  to  the  particular  individual. 

Very  slight  mental  disturbances  at  the  time  of  attempted  inter- 
course may  result  in  temporary  impotence.  Anxiety  or  mental 
worry  of  any  kind  may  cause  it.  Individuals  who  have  labored 
mentally  or  physically  to  the  extent  of  producing  exhaustion  are 
likely  to  experience  temporary  inhibition  of  sexual  activity  and 
desire.  This  physiologic  phenomenon  may  be,  as  already  has  been 
suggested,  taken  advantage  of  in  the  treatment  of  sexual  disorders. 
Emotional  influences  that  are  capable  of  making  a  powerful  im- 
pression upon  the  nervous  system  especially  tend  to  inhibit  sexual 
desire,  the  more  particularly  as  they  tend  to  check  the  secretion  of 
semen.  The  influences  that  tend  to  produce  activity  of  secretion 
of  the  testes  are  chiefly  emotional,  and,  conversely,  diverse  mental 
influences  may  check  the  secretion.  Carter  outlined  this  fact  as 
follows : — 

The  glands  liable  to  emotional  congestion  are  those  which,  by  forming 

—  120  — 


IMPOTKNCR   IN   TFTE   ^lALE 

their  products  in  larger  quantity,  subserve  to  the  gratification  of  the  excited 
feeling.  Thus,  blood  is  directed  to  the  mamma:  by  the  maternal  emotions, 
to  the^  testes  by  the  sexual  and  to  the  salivary  glands  by  the  influence  of 
appetizing  odors  ;  while  in  either  case  the  sudden  demand  may  produce  an 
exsanguine  condition  of  other  organs,  and  may  check  some  function  which 
was  being  actively  performed,  as,  for  instance,  the  digestive. 

Lack  of  secretion  has  a  mechanic  bearing  on  sexual  desire  and 
impotence.  When  the  secretions  of  the  testes  and  seminal  vesicles 
are  abimdant,  the  vesicles  become  distended  and  directly  and  re- 
flexly  excite  desire  by  mere  pressure.  The  individual  whose  vesicles 
quickly  refill  after  emptying,  soon  experiences  another  erection  with 
accompanying  sexual  desire.  Activity  of  secretion,  therefore,  is  an 
important  factor  in  analyzing  the  causes  and  treatment  of  impotence. 
This  explains  the  service  sometimes  rendered  by  pilocarpin.  It 
must  be  remembered,  however,  that  there  is  interaction  between 
sexual  passion  and  the  distention  of  the  seminal  vesicles.  While 
the  vesicles  become  more  or  less  rapidly  distended  even  where  no 
sexual  desire  exists,  they  fill  under  the  influence  of  sexual  passion 
with  a  rapidity  that  is  in  direct  ratio  to  the  degree  and  duration  of 
the  stimulation.  It  is  obvious  that  exhausting  diseases  act  in  several 
ways,  viz.:  1.  by  diminishing  secretion,  2.  by  disturbing  sexual 
innervation,  3.  by  diminution  and  perturbation  of  hormone  forma- 
tion, 4.  by  toxemia,  5.  by  reducing  general  bodily  vigor. 

The  emotion  of  fright  or  the  condition  of  mind  produced  by 
the  fear  of  detection  or  of  the  results  of  copulation  invariably  will 
inhibit  the  sexual  power.  Disgust,  indiiTerence,  or  antipathy  for  the 
party  of  the  second  part  often  has  a  similar  efifect. 

The  practical  physician  does  not  usually  put  much  faith  in  the 
theory  of  affinity  as  existing  between  the  sexes,  but  the  author  is  of 
opinion  that  in  many  instances  failure  to  consummate  the  marital 
act  is  due  to  a  lack  of  harmony  between  the  contracting  parties. 
An  apparent  instance  of  this  is  the  following: — 

Case. — A  man  31  years  of  age,  perfectly  healthy,  the  sexual  organs  be- 
ing perfectly  formed  and  apparently  in  a  normal  condition,  came  to  the 
author  for  relief  of  impotence.  He  was  a  man  of  very  highly-wrought 
nervous  organization,  and  had  never  been  anything  of  a  roue.  The  only  pos- 
sible exception  that  could  be  taken  to  his  physical  condition  was  the  fact 
that  he  was  somewhat  inclined  to  corpulence.  He  stated  that  he  had  not 
experienced  an  erection  for  some  months.  During  this  time,  however,  he  had 
been  working  very  hard,  and  had  not  allowed  his  mind  to  dwell  on  sexual 
matters,  and  he  himself  was  inclined  to  attribute  the  absence  of  erections  to 

~  121  — 


IMPOTENCE  AND   STERILITY 

this  fact.  As  he  contemplated  matrimony,  however,  he  desired  a  course  of 
treatment.  On  inquiry  he  stated  that  he  had  on  several  occasions  failed  in 
accomplishing  intercourse,  but  that  he  had  found  that  with  certain  females 
he  was  perfectly  potent,  while  with  others  he  was  absolutely  impotent.  He 
was  assured  that  there  was  no  physical  impediment  to  matrimony,  and  a 
course  of  local  faradization  was  advised.  He  improved  very  rapidly,  and 
in  a  few  months  the  sexual  function  became  so  active  that  the  bougie  elec- 
trode could  not  be  passed  because  the  slightest  contact  with  the  urethra  pro- 
duced vigorous  erection.  He  stated  that  when  he  took  a  Turkish  bath,  as 
per  advice,  he  was  considerably  embarrassed  by  the  occurrence  of  erections 
so  soon  as  the  attendant  attempted  to  rub  him.  Under  these  circumstances 
the  author  felt  perfectly  justified  in  advising  matrimony.  The  result  was 
unfortunately  not  what  had  been  expected,  for  a  year  after  marriage  he 
had  not  yet  succeeded  in  accomplishing  intercourse.  There  was  evidently 
in  this  casej  some  inhibitory  cause  of  a  mental  character,  as  shown  by  the 
fact  that  after  marriage  he  still  had  vigorous  erections  and  nocturnal  emis- 
sions with  dreams.  As  soon  as  the  idea  of  attempting  intercourse  entered 
his  mind  he  found  it  absolutely  impossible  to  secure  an  erection.  The 
author  finally  succeeded  in  curing  this  case  by  the  exercise  of  a  little  ingenuity. 
The  wife  was  sent  away  for  three  months,  the  husband  being  meanwhile 
treated  with  electricity.  On  the  day  of  the  wife's  home-coming  the  patient 
was  provided  with  a  rectal  suppository  containing  a  little  belladonna,  opium, 
and  camphor.  He  was  instructed  to  insert  this  on  going  to  bed  and  was  as- 
sured that  the  wonderful  suppository  never  failed.  The  treatment  was  a 
brilliant  success  and  there  was  no  future  trouble,  the  wife  becoming  preg- 
nant within  a  few  weeks. 

A  sensitive  sexual  organization  is  part  of  the  price  man  has 
paid  for  civiHzation.  The  more  refined  the  organization  of  the 
human  rule,  the  more  likely  he  is  to  suffer  from  impotence  due  to 
psychic  impressions.  Laying  aside  organic  causes,  the  savage  and 
the  lower  animals  do  not  experience  impotence.  The  human  male 
who  can  perform  the  sexual  act  under  any  and  all  environmental 
conditions  probably  is  an  example  of  atavism,  where  —  exceptionally 
—  it  does  not  prove  neuro-psychic  degeneracy.  The  commission 
of  rape,  in  the  author's  opinion,  is  sure  evidence  of  atavism. 

The  male  sex  is  not  alone  in  paying  the  price  of  civilization. 
The  female  also  has  been  sexually  penalized  for  her  upward  progress 
from  the  social-primitive  to  the  civilized  type.  Among  the  penalties 
are,  frigidity  in  many,  frequent  sexual  neuro-degeneracy  —  as 
evidenced  by  nymphomania  — ■  relative  or  complete  infertility,  and  an 
artificially  created,  so-called  normal  desire  persisting  during  utero- 
gestation  in  a  certain  proportion  of  women.  Repression  of  sexual 
desire,  through  religious  and  other  social  inhibitions,  has  had  a  very 

—  122  — 


IMPOTENCK   TX   THE   MALE 

powerful  influence  on  civilized  woman.  With  many,  sexual  passion 
develops  only  in  response  to  the  demands  of  the  male.  It  is  probable 
that  the  sex  habits  of  our  pre-human  ancestors,  the  female  of  which 
experienced  sexual  desire  —  the  breeding  instinct  —  only  at  certain 
stated  periods,  would  have  persisted  in  their  human  descendants  if 
social  environmental  influences  had  not  been  brought  to  bear.  It  is 
probable  that  any  sexual  desire  on  the  part  of  the  female  manifested 
at  any  time  other  than  shortly  before,  during  and  after  the  menstrual 
period,  has  been  acquired  in  response  to  the  sex  demands  of  the  male. 
Certain  it  is,  also,  that  nature  never  intended  that  the  female  of  any 
species  should  either  cohabit  during  pregnancy,  or  experience  sexual 
desire  at  such  a  time.  Once  pregnancy  has  occurred,  the  function 
for  which  the  sexual  act  was  intended  has  been  subserved  so  far  as 
the  female  is  concerned. 

Society's  attitude  towards  the  matrimonial  cjuestion  is  based 
largely  upon  mawkish  sentiment,  ignorance  of  biologic  law,  and 
the  impracticability  of  its  application  in  every-day  life.  The  average 
moralist,  accepting  marriage  as  a  divine  institution  instead  of  what 
it  really  is  —  a  conventionalized  regulation  of  sex  love  via  a  civil, 
business  and  social  contract  —  sees  nothing  in  the  problem  save 
conformity  or  non-conformity  to  divine  law.  Quite  naturally  he 
cannot  conceive  of  such  a  thing  as  divine  error  and  consequently 
is  dominated  entirely  by  the  "Tied  you  are,  and  tied  you  must  stay" 
dogma.  From  this  point  of  view  there  can  be  no  such  thing  as 
marital  mistakes  to  be  rectified.  In  certain  quarters,  therefore, 
infallibility  of  matrimonial  selection  primarily  is  taken  for  granted 
and  invariably  demanded.  It  is  noteworthy  that  marriage  is  the 
only  human  act  in  which  anybody  ever  expects  infallibility  of 
judgment. 

Unfortunately,  however,  marriage  in  real  life  is  a  strictly 
human  institution  in  which  the  contracting  parties  are  not  demigods, 
but  fallible  human  beings,  fundamentally  jwssessed  of  certain  animal 
traits  which  are  a  rather  heavy  handicap  to  the  intellectual  attributes 
that  are  distinctively  human.  ]\Iarriage  necessarily  is  experimental. 
As  a  rule,  neither  of  the  contracting  parties  has  any  means  of 
knowing  the  true  character  of  the  other.  The  young  man  who 
goes  courting  dons  his  best  behavior  with  his  best  clothes.  The 
young  woman  courted,  not  to  be  outdone  at  woman's  own  game, 
lays  even  greater  stress  upon  externals.     She  puts  on  her  prettiest 

—  123  — 


IMPOTENCE  AND   STERILITY 

gown  and  "company  manners"  and  does  her  best  to  conceal,  not 
only  her  physical  defects,  but  her  mental  and  moral  flaws.  Her 
mission  in  life  is  to  catch  a  husband  —  honestly  if  she  can,  but  to 
catch  him.  If  either  one  is  inexperienced,  the  game  is  an  easy  going 
one,  and  the  end  assured ;  propinquity  assists  the  fraud.  Rarely  is 
there  a  critical  study  of  character  on  either  side.  When  love 
dominates,  the  loved  one  is  beyond  criticism  and  there  is  no  incentive 
to  character  study. 

After  marriage  both  parties  to  the  arrangement  sooner  or  later 
become  more  critical.  Marriage  is  a  steady  and  intimate  association 
which  only  compatibles  can  face  without  disaster.  The  rose  tints 
of  the  pre-marital  ideal  become  rather  murky  when  incompatibility 
once  becomes  manifest. 

Compatibility  involves  several  elements  that  only  intimate 
association  can  discover.  Broadly  speaking,  these  may  be  either 
physical  or  psychic,  the  qualities  that  attract  or  repel  being  some- 
times blended  so  that  it  is  difficult  to  determine  where  the  one 
terminates  and  the  other  begins.  Psychic  impressions  modify  the 
physical  and  vice  versa.  The  resulting  complex,  modified  by  the 
couple's  imaginations,  may  or  may  not  correspond  to  their  pre- 
marital ideals.  That  such  ideals  should  be  so  often  shattered  is  not 
astonishing.  Ideals  based  entirely  upon  externals,  and  the  super- 
structure of  which  is  built  up  from  an  imagination  dominated  by 
psycho-sexual  erethism,  are  greatly  handicapped  in  their  contest 
with  the  psychic  and  physical  realities  of  life. 

Under  natural  conditions,  the  physical  is  far  more  important 
than  the  psychic  in  the  question  of  mating.  Sex  attraction  is  a 
purely  animal  attribute  which,  invest  it  as  we  may  with  a  halo  of 
sentiment  and  romance,  is  none  the  less  a  primitive  biologic  instinct 
that  is  common  to  all  species.  Civilization  and  its  attendant  refine- 
ments have  added  the  psycho-sexual  to  the  purely  animal,  but  as 
yet  the  former  by  no  means  dominates  matrimonial  selection,  nor 
would  the  best  interests  of  the  race  be  conserved  by  its  domination. 
The  unlike  attracts  and  the  like  repels,  here  as  elsewhere.  If  the 
large,  powerful  man  usually  selected  a  woman  built  upon  similar 
lines,  and  the  small  man  the  small  woman,  we  in  time  would  have 
two  races  side  by  side  —  one  of  dwarfs  and  the  other  of  giants. 
Should  intellectual  persons  always  gravitate  together,  procreation 
finally  would  cease  and  the  race  would  run  out,  dying  at  the  top, 

—  124  — 


IMPOTENCE   IX   THE   MALE 

after  passing  through  all  the  degrees  of  physical  and  mental  degen- 
eration. As  a  n^.atter  of  fact,  the  natural  tendency  of  human  beings 
to  select  mates  of  opposite  characteristics  has  been  conservative, 
and  has  tended  to  maintain  a  certain  racially  healthful  physical  and 
mental  average. 

It  is  true  that  the  tendency  to  rise  superior  to  the  purely  physical 
in  matrimonial  selection  is  increasing,  pari  passu  with  the  progress 
of  civilization  and  the  increasing  complexity  of  human  life  —  but 
so  is  the  business  of  the  divorce  courts,  and  so,  also,  is  degeneracy. 
]^Ien  and  women  are  growing  more  and  more  selfish  and  exacting. 
The  family  is  coming  to  be  less  their  concern,  hence  the  qualifications 
of  the  given  member  of  the  opposite  sex  for  parenthood  are  of 
diminishing  importance.  The  demand  for  congenial  companionship 
is  greater  and,  as  the  test  can  be  made  only  after  marriage,  mental 
incompatibility  necessarily  has  become  more  prominent  in  matri- 
mony. The  psychic  element  primarily  is  purely  artificial,  and  there- 
fore less  stable  than  the  purely  physical.  The  savage  does  not  prate 
of  incompatibility.  With  him  the  question  is  altogether  a  physical 
one.  The  physical  element,  however  nnich  modified  by  civilization, 
still  being  dominant  in  matrimony,  the  proportion  of  marital  dis- 
harmonies is  as  yet  relatively  small,  although  it  is  steadily  growing. 

Purely  physical  incompatibility  probably  is  the  exception,  yet, 
as  all  physicians  know,  is  more  frequent  than  is  generally  supposed. 
It  is  not  manifest  in  frigidity  alone,  for  in  many  instances  there  is 
an  instinctive  repugnance  to  physical  contact,  yet  there  really  is  no 
frigidity,  and  psychic  conditions  apparently  are  ideal. 

Reduced  to  its  biologic  ultimate,  sex  attraction  requires  no 
more  psychic  explanation  than  does  chemical  affinity,  and  yet  the 
fact  remains  that  many  human  beings  go  through  life  without 
meeting  their  sex  "complement."  Some  know  what  they  have 
missed ;  the  majority,  fortunately,  do  not.     "Ignorance  is  bliss." 

The  author  is  well  aware  that  ideals  of  all  kinds  usually  are 
assigned  to  the  realm  of  spiritual  things,  and  is  willing  to  acknowl- 
edge that  the  hyperesthetic  psycho-sexuality  of  civilized  races  has 
much  to  do  with  the  construction  of  sex  ideals,  but  he  nevertheless 
is  convinced  that  the  question  of  physical  affinity  is  to  be  given 
serious  consideration.  It  is  here  that  the  author  would  take  issitc 
with  the  purely  spiritual  conception  of  the  ideal.  The  instance  of 
childless    couples    who    have    been    divorced    and    remarried,    each 

—  125  — 


IMPOTENCE  AND   STERILITY 

taking  the  partner  of  the  other,  with  resultant  f ruitfulness,  certainly 
has  a  biologic  explanation  that  is  well  worth  consideration.  When 
a  beautiful,  refined,  and  intellectual  woman,  surrounded  by  every 
luxury,  runs  away  with  a  coarse,  unattractive  stable-hand,  the 
spiritual  ideal  is  a  dubious  explanation. 

Where  the  physical  conditions  of  married  persons  are  absolutely 
harmonious,  mental  incompatibility  is  unusual.  Where  one  or  the 
other  is  a  high-strung,  neurotic  individual,  however,  the  psychic 
element  is  likely  to  be  discordant.  Should  both  be  neurotic,  com- 
patibility is  almost  impossible.  Sentiment  gradually  is  submerged 
until  there  is  left  a  physical  reality  that  contains  no  suggestion  of 
the  ideal. 

In  most  cases  of  marital  infelicity,  it  is  safe  to  say  that  the 
husband  is  at  fault.  There  is  a  very  cogent  reason  for  this.  He 
usually  has  in  mind  a  physical  standard  based  upon  previous  ex- 
periences. While  the  glamour  of  early  married  life  lasts,  he  is 
satisfied  with  the  situation.  The  inexperience  of  the  wife  primarily 
is  a  decided  novelty.  When,  however,  satiety  arrives,  as  it  usually 
does  sooner  or  later,  he  recalls  memories  of  past  experiences  in  the 
light  of  which  the  physical  charms  of  the  wife  begin  to  pale.  He 
soon  discovers  [)hysical  incompatibility,  and  resumes  the  pursuit  of 
elusive  past  sexual  impressions  that  his  marriage  temporarily  inter- 
rupted. His  relations  with  his  wife  perhaps  began  practically  with 
legalized  rape,  that  served  to  make  permanent  and  incurable  any 
qualities  of  frigidity  which  she  primarily  may  have  possessed.  For 
her,  the  marital  relation  is  only  a  painful  and  disgusting  memory 
inspiring  her  with  abhorrence. 

In  many  cases  moral  degeneracy  on  one  or  both  sides  is  the 
cause  of  infelicity.  The  anti-social  instincts  of  the  degenerate  are 
as  manifest  in  the  matrimonial  relation  as  they  are  elsewhere. 

The  undue  familiarity  usually  existing  between  husband  and 
wife  is  a  feeder  of  psycho-sexual  aberrations.  Once  the  halo  of 
sex  mystery  is  dispelled,  romance  often  fades  completely.  The 
author  is  firmly  convinced  that  a  less  intimate  association  of  husband 
and  wife  would  be  better  for  both  health  and  morals.  The  less 
knowledge  they  have  of  each  other's  physiology,  the  better  for 
sentiment.  Privacy  is  an  individual  right,  in  or  out  of  matrimony. 
Familiarity  breeds  satiety.  Satiety  is  the  parent  of  sexual  discon- 
tent. The  satiated,  discontented  man  often  browses  in  queer  pastures 

—  126     - 


IMPOTENCE  IN   THE   MALE 

in  search  of  new  thrills  for  his  exhausted  psycho-sexual  centers 
Often  he  is  unable  to  find  them  save  in  debasement  that  would 
astonish  his  intimates,  but  is  not  at  all  remarkable  to  the  student 
of  sex  psychology.  Granting  that  the  foregoing  premises  are  sound, 
they  should  go  far  in  showing  that,  in  many  cases  of  impotence 
and  sterility,  the  divorce  court  and  a  matrimonial  "rearrangement" 
must  be  the  final  recourse.  Every  man  and  woman  of  experience 
and,  above  all,  every  physician,  knows  this,  but  nobody  apparently 
has  had  the  courage  to  openly  state  the  facts.  Meanwhile,  the 
divorce  mills  grind  merrily  on  and  students  of  social  questions 
continue  to  use  only  economic  and  moral  explanations  for  certain 
biologic  phenomena  of  matrimony,  whilst  physicians  daily  are  asked 
to  perform  impossible  therapeutic  feats. 

That  certain  individuals  of  highly-sensitive  nervous  organization 
are  impotent  respecting  some  women,  while  with  others  they  are 
perfectly  potent,  is  a  well-known  fact.  Individuals  of  this  sort 
very  often  are  convinced  that  they  are  impotent,  by  failure  in 
experimenting  with  prostitutes  for  the  purpose  of  determining 
whether  or  not  they  are  justified  in  assuming  the  matrimonial  state. 
The  fact  that  they  are  impotent  under  such  circumstances  is  highly 
complimentary  to  their  moral  tone.  The  environment  that  surrounds 
the  average  prostitute,  in  conjunction  with  the  purely  mercantile 
character  of  the  transaction,  is  not  likely  to  inspire  with  sexual 
passion  an  individual  possessed  of  the  average  amount  of  decency 
and  self-respect.  It  is  not  unusual  for  individuals  to  state  that, 
excepting  when  under  the  influence  of  liquor,  they  are  absolutely 
impotent  with  prostitutes.  Considerable  and  forcible  argument  may 
be  necessary  to  convince  patients  who  have  applied  what  they  con- 
sider the  crucial  test  of  attempting  intercourse  with  prostitutes,  and 
have  failed,  that  they  are  not  impotent. 

Roubaud  records  a  case  which,  although  it  has  become  so 
extensively  quoted  by  writers  upon  the  subject  that  it  has  been 
worn  almost  threadbare,  is  nevertheless  very  pertinent  as  applied 
to  patients  who  are  psychically  impotent  with  some  women,  while 
perfectly  potent  with  others  : — 

Case. — M.  X.,  son  of  a  general  of  the  First  Empire,  was  brought  up  at 
his  father's  country-seat,  which  he  did  not  leave  until  he  was  eighteen  years 
of  age,  when  he  went  to  the  military  school.  During  his  long  period  of  iso- 
lation in  the  country  he  had  been  initiated,  at  the  age  of  fourteen,  into  an 

—  127  — 


IMPOTENCE  AND   STERILITY 

experience  of  the  pleasures  of  love,  by  a  young  lady,  a  friend  of  the  family. 
This  lady,  then  twenty-one  years  old,  was  a  blonde ;  wore  her  hair  in  the 
English  style,  that  is  to  say,  in  corkscrew  curls ;  and  in  order  to  lessen  the 
liability  of  detection  in  her  amorous  intrigue,  she  never  had  intercourse  with 
her  young  lover  except  when  clothed  in  her  day  attire, — that  is  to  say,  wear- 
ing gaiter-boots,  corsets,  and  a  silk  gown. 

All  these  details  I  mention  purposely,  for  they  had  great  influence,  not 
only  over  the  degree  of  excitability  of  the  genital  function,  but  over  its  very 
existence  in  the  case  of  M.  X. 

The  young  lady  was  of  strong  passions,  and,  as  it  appeared,  exhausted 
the  strength  of  the  young  neophyte,  and  the  severe  regimen  of  the  military 
school  was  no  more  than  sufficient  to  restore  to  the  genital  organs  the 
energy  which  had  been  seriously  affected  by  too  early  and  too  frequent  in- 
dulgence. 

But  when,  the  period  of  his  study  having  passed,  he  was  sent  to  a  gar- 
rison, and  was  disposed  to  enjoy  the  rights  which  nature  had  restored,  he 
perceived  that  sexual  desire  was  only  provoked  by  certain  women  and  with 
the  concurrence  of  certain  circumstances.  Thus,  a  brunette  did  not  produce 
in  him  the  slightest  emotion,  and  a  woman  in  her  night-dress  was  sufficient 
to  extinguish  and  freeze  every  amorous  transport. 

In  order  that  he  might  experience  the  venereal  desire,  it  was  necessary 
that  the  woman  should  be  blonde,  should  wear  gaiter-boots,  should  be  laced 
in  a  corset,  wear  a  silk  gown,  and,  in  a  word  fulfill  all  the  requirements  of 
the  lady  who  had  first  caused  M.  X.  to  experience  the  sexual  orgasm. 

And  this  was  not  by  reason  of  any  sentimental  love,  the  magic  power 
of  which  lasts  through  a  life-time.  In  his  early  sexual  relations  M.  X.  had 
only  been  actuated  by  animal  desire.  His  heart  had  never  been  touched,  and 
after  twenty-five  years,  in  consulting  me  for  his  singular  infirmity,  he 
declared  that  he  had  loved  with  his  heart  but  one  woman,  and  to  her  he  had 
never  been  able  to  render  homage,  for,  by  a  perverse  coincidence,  she  was  a 
brunette. 

His  fortune,  his  name,  his  social  position,  made  it  the  duty  of  M.  X. 
to  marry,  but  he  had  always  resisted  the  solicitations  of  his  family  and 
friends,  knowing  that  he  would  be  incapable  of  availing  himself  of  his  marital 
rights,  with  a  wife  arrayed  in  the  costume  of  the  nuptial  bed.  Yet  he  was 
in  good  health,  was  of  the  sanguino-choleric  temperament,  was  above  the 
medium  height,  and  was  of  so  strong  a  constitution  that  for  fifteen  years 
he  had  been  an  officer  in  a  regiment  of  heavy  cavalry. 

Evidently  his  impotence  was  relative  only,  for,  when  the  woman  was 
blonde  and  when  the  other  conditions  specified  existed,  he  accomplished 
the  sexual  act  with  all  the  ardor  of  a  healthy  man  of  amorous  disposition. 

Roiibaiid  finally  cured  this  patient  by  suggestion,  in  conjunction 
with  the  use  of  alcoholic  stimulants  to  the  point  of  mild  intoxication. 
The  spell  once  broken,  there  was  no  further  trouble. 

vSuch  psycho-sexual  inhibitions  as  the  case  related  by  Roubaud 

—  128  ~ 


1.MPOTENCI-:   IN   THE   MALE 

arc  more  frequent  than  is  generally  supposed.  Prolonged  sexual 
relations  with  an  individual  of  a  certain  type  not  infrequently  makes 
such  a  profound  psychic  impression  that  other  types  of  women  are 
unattractive.  Especially  is  this  true  of  men  of  tine  nervous  organ- 
ization who  happen  to  consort  with  women  of  decided  blonde  or 
brunette  type.  Prolonged  association  with  one  type  by  no  means 
rarely  makes  the  other  unattractive,  sometimes  even  repellent.  This, 
of  course,  is  not  always  a  matter  merely  of  physique.  Certain 
intellectual  attributes  in  the  woman  may  have  much  to  do  with  the 
psycho-sexual  impression  she  produces. 

Cases  have  been  noted  in  which  pseudo-impotence  was  relieved 
by  the  affected  individual's  picturing  in  his  imagination  the  person 
of  some  woman  other  than  the  one  with  whom  he  was  attempting 
to  cohabit.  In  certain  impressionable  individuals  impotence  may 
result  from  a  lack  of  affinity  between  the  parties  to  the  act,  actual 
antipathy  on  the  part  of  either  being  unnecessary  to  its  causation, 
Goethe  took  advantage  of  this  physiologic  fact  in  his  "Elective 
Affinities."  In  this  tale  is  described  the  mutual  enjoyment  obtained 
by  an  estranged  couple  through  the  medium  of  their  imaginations, 
each  party  to  the  act  imagining  the  other  to  be  the  individual  for 
whom  an  affinity  was  felt.  Goethe  carries  the  theory  of  affinity 
still  further,  and  describes  the  child  that  was  born  as  the  fruit  of 
this  particular  conjugal  act  as  in  no  way  resembling  its  parents,  but 
presenting  a  strong  resemblance  to  both  individuals  for  whom  the 
parents  respectively  felt  an  affinity,  and  who  were  present  in  imagi- 
nation at  the  time  of  conception. 

Hammond  relates  a  Ccipe  that  is  aptly  illustrative  of  the  manner 
in  which  certain  mental  conditions  will  produce  temporary  im- 
potence : — 

Case. — A  married  gentleman,  who  before  entering  into  the  matrimonial 
state,  had  been  excessively  given  to  sexual  intercourse,  but  vi^ho  had  no  rea- 
son to  think  that  his  powers  were  exhausted,  or  even  materially  weakened, 
found  himself  on  his  wedding-night  and  for  some  days  thereafter  absolutely 
incapable  of  consummating  the  marriage.  His  wife  was  a  highly-educated, 
intelligent,  refined,  and  beautiful  woman ;  he  was  devotedly  attached  to  her, 
and  on  marrying  at  once  and  for  all  gave  up  the  evil  associations  of  his 
younger  days.  His  passions  were  strong,  but  as  soon  as  he  attempted  inter- 
course the  desire  he  had  previously  entertained  vanished  at  the  thought  that 
it  was  a  profanation  for  a  man  like  him  to  subject  so  beautiful  and  pure  a 
woman  to  such  an  animal  relation  as  sexual  intercourse.     "She  is  too  good 

—  129  — 


HTPOTKNCE   AND   STERILITY 

for  me,"  he  would  say  to  himself ;  "I  ought  to  have  married  a  woman  used 
to  this  sort  of  thing,  or,  better  still,  have  remained  single  and  gone  on  in 
the  old  way."  This  happened  several  times,  and  then,  in  disgust  with  him- 
self, he  paid  a  visit  to  one  of  his  former  female  associates,  and  soon  satis- 
fied himself  that  his  powers  were  as  good  as  ever.  Again  he  essayed  the 
act  with  his  wife,  and  again  he  met  with  disappointment. 

He  had  now  been  married  a  week,  and  the  marriage  was  still  uncon- 
summated. 

A  case  like  this  presented  very  little  difficulty :  I  reminded  him  of  the 
fact  that  in  all  probability,  however  pure  and  noble  his  wife  might  be,  there 
was  no  profanation  in  sexual  intercourse,  chastely  undertaken;  that  she 
had  sexual  organs  which  were  intended  for  the  performance  of  certain  func- 
tion ;  that  these  functions  were  all  connected  with  the  propagation  of  the 
human  species ;  that  there  was  but  one  way  that  I  knew  of  by  which  the 
species  could  be  propagated ;  that  she  had  selected  him  as  the  man  who  was 
to  put  her  in  the  way  of  fulfilling  her  office  in  the  grand  scheme  of  Nature, 
and  that  my  advice  to  him  was  to  lower  his  estimate  of  her  angelic  char- 
acter, and  to  look  upon  her  in  the  not  less  worthy  light  of  a  woman  to  be 
treated  as  other  women  are  treated  under  like  circumstances.  He  left, 
promised  to  be  less  exalted  in  appreciation,  but  the  next  morning  returned 
with  the  information  that  it  was  no  use ;  he  had  tried  his  best,  his  erections 
were  strong  and  repeated,  but  as  soon  as  he  went  further  toward  the  object 
he  had  in  view  his  desire  became  utterl}'  extinguished.  She  was  "too  good, 
too  delicate,  for  a  mere  animal  like  him ;  he  could  not  desecrate  her  beauti- 
ful body  by  any  such  vile  act,"  etc. 

With  the  sensible  co-operation  of  the  wife,  Hammond  had  no 
difficulty  in  curing  this  case  by  suggestion. 

Sexual  perversion  may  cause  impotence.  It  is  obvious  that 
individuals  for  whom  the  natural  method  of  performance  of  the 
sexual  act  has  no  attraction  are  likely  to  fail  should  they  attempt  it. 
Impotence  of  a  transitory  character  may  be  due  to  the  psychic 
effect  of  satiety  as  well  as  to  the  debilitating  influence  of  sexual 
excess.  This  is  the  form  of  impotence  most  freqttently  seen  in 
married  men.  Through  resulting  psychic  perturbation,  a  lack  of 
responsiveness  on  the  part  of  the  female  is  an  occasional  cause  of 
pseudo-impotence  in  the  male.  This  is  especially  likely  to  arise  in 
married  men  and  probably  in  the  majority  of  instances  is  primarily 
their  own  fault. 

The  proper  ftmctioning  of  the  sex  glands,  probably  is  more 
dependent  on  environmental  conditions  than  are  the  secretions  of 
any  of  the  other  important  organs  of  the  body.  The  functions  of 
the  digestive  organs,  salivary  glands,  liver  and  mammary  glands 
are  pertitrbed — through  disturbances  of  the  nervous  and  sympathetic 

—  130  — 


IMPOTENCE   IN   THE   MALE 

centers  —  by  such  emotions  as  jealousy,  worry,  anger,  disgust  or 
fright.  The  perversion  or  suppression  of  the  lacteal  secretion 
through  adverse  —  and  their  increased  activity  from  favorable  — 
psychic  influences  is  especially  suggestive.  The  disastrous  effect 
upon  the  child  produced  by  toxins  developed  in  the  mother's  milk 
by  fright,  anger,  jealousy  and  grief  are  familiar  to  every  practi- 
tioner of  experience.  Even  the  cow  —  which  certainly  cannot  be 
accused  of  a  highly  refined  psycho-emotional  organization  —  suffers 
from  diminution  or  perversion  —  or  both  —  of  milk  supply  from 
disturbing  influences.  In  this  connection  the  important  physiologic 
relation  of  the  mammary  glands  and  sexual  organs  is  very  sug- 
gestive. 

Why,  then,  should  we  expect  the  sexual  organs,  which  are  still 
more  actively  dominated  by  emotional  influences  via  the  sympathetic 
than  are  other  organs,  to  be  less  sensitive  to  such  impressions  than 
they  ? 

In  direct  ratio  to  the  degree  to  which  potency  and  fertility  are 
determined  by  the  proper  performance  of  the  function  of  the  testis 
and  ovary,  and  upon  the  innervation  and  vascular  supply  of  erectile 
tissue,  will  be  the  evil  effect  of  adverse  psychic  influences.  The 
shrew,  the  termagant,  the  virago  and  the  indifferent  female  will 
please  take  notice. 

With  respect  to  the  sexual  act  per  sc,  adverse  psychic  conditions 
are  not  so  serious  in  their  effects  upon  the  female  as  upon  the  male, 
merely  because  they  do  not  throw  any  mechanical  obstacles  in  the 
way  of  coitus.  The  indifferent  female  can  conceal  her  aversion  to 
the  sexual  act.  Not  so  the  male,  for  with  aversion  or  frigidity  on 
his  part  comes  the  impossibility  of  its  performance.  The  same  may 
be  said  of  such  influences  as  fear,  worry,  etc.  On  the  other  hand, 
in  the  matter  of  fertility  and  sexual  passion,  adverse  psychic  in- 
fluences have  an  important  bearing  on  the  sexual  function  of  the 
female. 

In  searching  for  the  causes  of  impotence  and  sterility  in  married 
life,  the  i)hysician  should  carefully  seek  for  possible  psycho-sexual 
disharmony  of  various  kinds  and  degree.  No  method  of  treatment 
of  impotence  can  succeed  v/here  pronounced  marital  disharmony 
exists  and  cannot  be  removed.  To  be  sure,  domestic  quarrels  may 
be  followed  by  exaltation  of  sexual  desire,  but  these  instances  are 
the  exception  —  and  besides,   there   really   may  be   no   sexual   dis- 

—  131  -^ 


IMPOTENCE  AND   STERILITY 

harmony  or  aversion  in  such  cases.  Then,  too,  the  easily  aroused 
temper  is  Hkely  to  be  associated  with  an  ardent  sex  temperament, 
to  the  fire  of  which  "making  up"  domestic  quarrels  merely  adds  fuel. 

When  the  wife  ridicules  her  husband's  sexual  disability,  ex- 
presses disgust  or  dissatisfaction  with  the  sexual  act,  accuses  the 
husband  of  infidelity  as  an  explanation  of  his  marital  sexual  ineffi- 
ciency, exhibits  indifiference  to  the  act,  or  complains  of  pain  in 
coitus,  relative  impotence  in  the  husband  develops  sooner  or  later 
and,  so  long  as  the  adverse  psychic  conditions  prevail,  the  condition 
is  irremediable. 

The  man  or  woman  whose  attitude  is  that  of  the  man  who, 
having  caught  the  street  car,  ceases  to  "run  after  it,"  is  on  dangerous 
ground.  Couples  who,  after  marriage,  take  everything  for  granted 
and  cease  to  exert  themselves  to  perpetuate  mutual  sex  attraction, 
always  are  on  thin  ice. 

The  thinking  physician,  knowing  the  inside  history  of  matri- 
monial mesalliances,  is  likely  to  be  astonished,  not  at  the  frequency 
of  marital-sexual  disharmony,  but  that  there  is  not  even  more  of  it. 

The  author  recalls  a  number  of  very  interesting  cases  bearing 
on  the  problem  of  the  relation  of  marital  disharmony  to  impotence. 
One  of  the  most  typic  was  the  following: 

Case  : — A  professional  man,  thirty-five  years  of  age,  had  been  gradually 
developing  impotence  for  four  or  live  years  until  now  it  was  complete.  He 
had  been  married  for  ten  years  and  had  had  no  extra-marital  experiences. 
Beginning  after  a  prolonged  period  of  overwork  and  business  worries,  the 
trouble  finally  had  impelled  him  to  seek  medical  counsel.  He  showed  no 
organic  disease  and  physically  was  more  powerful  than  the  average  man 
of  his  age.  He  stated  that  he  had  moderately  vigorous  erections  but  little 
desire,  and  that  erection  always  failed  him.  He  denied  domestic  infelicity, 
but  in  such  wise  that  the  author  was  suspicious  that  his  denial  savored 
more  strongly  of  gallantry  than  truthfulness.  After  some  months  of  treat- 
ment, without  success,  resection  of  the  vena  dorsalis  penis  was  suggested 
and  performed,  with  excellent  results,  so  far  as  frequency  and  vigor  of 
erections  was  concerned.  He  still,  however,  was  impotent.  Several  months 
later  tlie  wife  called  upon  the  author  and  interrogated  him  regarding  her 
husband's  condition.  The  author  found  that  the  patient's  failure  to  recover 
his  potency  was  easily  explained.  The  wife  was  an  exacting,  shrewish  person 
and  suspicious  of  her  husband's  fidelity.  By  her  unfounded  accusations,  fault 
finding  and  ridicule  —  begun  at  the  time  the  husband's  virility  was  impaired 
by  .sheer  physical  exhaustion  —  she  finally  succeeded  in  permanently  inhibiting 
both  liis  power  and  desire.  Tlie  author  bluntly  stated  the  facts  to  both  parties 
nnd   did  his  l)cst   to   liarmonize  their   widely  divergent  psychic  attitudes,   but 

—  132  — 


IMPOTENCE  IN   THE   MALE 

without  result.     A  divorce  was  the  sequence,  about  a  year  later.     Two  years 
subsequently,  the  patient  married  again  and  since  has  been  perfectly  normal. 

Certain  phases  of  the  matrimonial  problem  are  of  vital  interest 
to  the  physician  who  is  interested  in  problems  involving  the  sexual 
function.  Society  bungles  the  matrimonial  qtiestion,  and  if  there 
ever  is  to  be  any  progress,  it  necessarily  will  be  largely  through  the 
educational  efforts  of  the  physician-sociologist. 

The  author  is  of  opinion  that  production  of  impotence  by 
psychic  influences  is  in  a  measure  explicable  by  the  hormone  theory. 
Worry,  aversion  and  other  adverse  sex  psychic  elements  may,  by 
disturbing  the  nutrition  of  the  glands,  pervert  or  inhibit  sex  hor- 
mone supply.  Absolutely  normal  sexual  relations  demand  certain 
favorable  conditions.  Love,  with  normal  environment,  and  a 
normal  ovary  and  testis,  are  great  stimulants  to  the  proper  formation 
of  the  sex  hormones. 

True  Impotenck. — True  impotence  is  rare  in  both  male  and 
female ;  extremely  so  in  the  latter.  The  function  of  the  male  in  the 
act  of  copulation  is  an  active  one,  and  erection  of  the  sexual  member 
is  necessary ;  w-hereas  in  the  case  of  the  female  no  preparation  is 
necessary  for  the  sexual  act,  her  function  being  comparatively 
passive.  The  necessary  element  in  the  case  of  the  male  is  a  sufficient 
degree  of  firmness  of  erection  to  permit  the  introduction  of  the  penis 
into  the  vagina,  and  any  individual  who  is  possessed  of  this  amount 
of  capacity  cannot  justly  be  said  to  be  afflicted  with  true  impotence. 
It  is  unnecessary  to  potency  that  the  individual  should  experience 
either  desire  for,  or  pleasure  in  the  performance  of,  the  act  of  copu- 
lation. In  certain  conditions  perfect  erection  and  even  ejaculation 
are  possible,  although  the  individual  does  not  experience  either  desire 
or  pleasure.  Some  of  the  diseases  affecting  the  spinal  medulla 
produce  this  phenomenon.  In  certain  cases  of  aspermatism  a  similar 
state  of  affairs  is  noted.  Severe  priapism  due  to  cantharidal  poison- 
ing is  not  usually  attended  by  sexual  desire,  and  intercourse  under 
such  circumstances  may  be  absolutely  devoid  of  pleasure. 

The  term  impotence  in  the  case  of  the  male  should  be  restricted 
to  those  cases  in  which  there  exists  some  actual  physical  impediment 
to  the  performance  of  the  act  of  copulation.  Such  impediment  may, 
however,  be  temporary  or  permanent. 

Etiology. — The  causes  of  true  impotence  may  be  classified  as 
(a)  congenital;  (b)  acquired. 

—  133  — 


IMPOTENCE  AND   STERILITY 

(a)  Congenital  Causes. — 1.  Marked  hypospadias  or  epispa- 
dias. In  some  cases  of  the  former  the  penis  is  curved  or  otherwise 
deformed.  In  the  latter  condition  exstrophy  of  the  bladder  may  co- 
exist. The  author  has  met  with  one  case  of  impotence  due  to  a 
congenital  lateral  curvature  of  the  penis. 

2.  Imperfect  development  of  the  penis  and  testes,  the  former 
being  too  small  and  too  flaccid  for  copulation.  Oftentimes  the  penis 
seems  overlarge,  yet  the  erectile  tissue  is  not  well  developed,  and 
erection  is  consequently  imperfect. 

3.  Congenitally-excessive  development  of  the  penis  (?).  This 
form  of  impotence  may  be  only  a  relative  affair,  the  real  cause 
being  a  disproportionate  smallness  of  the  vagina  of  the  individual 
with  whom  intercourse  is  attempted.  In  the  absence  of  tumors  it 
is  probable  that  the  cases  in  which  the  penis  is  too  large  to  permit 
of  copulation  are  extremely  rare,  if,  indeed,  they  ever  occur. 

4.  Cryptorchidism  or  monorchidism,  with  imperfect  develop- 
ment of  the  penis. 

5.  Excessive  redundancy  of  the  prepuce,  with  phimosis. 

6.  Congenital  tumors  of  the  organ. 

(b)  Acquired  Causes. — 1.  Tumors  of  the  penis,  prepuce,  or 
glans. 

2.  Inflammatory  thickening  of  the  prepuce,  with  phimosis,  inci- 
dental to  balanitis,  gonorrhea,  or  chancroid. 

3.  Large  venereal  vegetations. 

4.  Excessive  obesity.  This  cause  is  frequent,  but  is  sometimes 
overcome  by  the  ingenuity  of  the  patient  in  reversing  the  relative 
positions  of  the  male  and  female  during  copulation ;  an  expedient 
as  old  as  the  Decameron.    Obesity  also  lessens  desire. 

5.  Ankylosis  of  both  hips  may  prevent  copulation  in  the 
normal  manner,  although  by  appropriate  posturing  the  act  may  be 
accomplished,  at  least  by  the  male. 

6.  Tumors  of  the  scrotum  or  testes,  such  as  hydrocele,  sarco- 
cele,  hematocele,  cancer,  and  elephantiasis.  The  two  latter  condi- 
tions may  involve  the  penis. 

7.  Chancre  or  chancroid  of  the  penis  of  sufficient  size  and 
irritability  to  interfere  with  copulation  by  the  pain  the  act  pro- 
duces. 

8.  Gonorrheal  or  simple  urethritis. 

—  134  — 


IMPOTENCE   IN    THE   :MALE 

9.  Acute  or  chronic  chordee.  'J'he  former  condition  occurs  in 
gonorrhea ;  the  latter  may  resuh  from  frequent  and  severe  attacks 
of  ureth.ritis,  or  from  stricture,  and  may  occasionally  arise  as  a 
consequence  of  urethrotomy. 

10.  Inflammation  of  the  deep  urethra,  prostate,  and  seminal 
vesicles. 

11.  Circumscribed  inflammation  of  the  corpora  cavernosa.  In 
these  cases  calcareous  plates  sometimes  form. 

12.  Cicatrices  from  wounds  of  the  penis  or  urethra,  interfer- 
ing with  erection. 

13.  Removal  of  the  penis  and  testes.  If  the  operation  be 
performed  early  in  life  removal  of  the  latter  only  is  necessary. 

14.  The  habit  of  masturbation,  spermatorrhea  from  whatever 
cause,  nervous  shock,  and  in  some  instances  organic  disease  of  the 
brain  and  spinal  cord  may  produce  a  complete  and  permanent  loss 
of  power  of  erection  by  exhaustion  or  inhibition  of  the  nervous 
stimulus  to  the  parts. 

15.  Temporary  and  symptomatic  impotence  sometimes  is  the 
result  of  constitutional  diseases,  such  as  fevers.  Debilitating  and 
prostrating  acute  or  chronic  disease,  and  neurasthenia  from  over- 
work or  worry,  may  produce  it. 

For  several  years  the  author's  attention  from  time  to  time  has 
been  directed  to  a  form  of  inipotentia  coeundi  which,  so  far  as  its 
etiology  and  pathology  are  concerned,  hitherto  has  escaped  observa- 
tion. Cavernositis  chronica — -sclerosing  inflammation  of  the  cor- 
pora cavernosa  —  is  sufficiently  familiar  to  the  genito-urinary 
surgeon,  at  least,  but  the  dependence  of  the  alTection  on  a  general 
systemic  condition  apparently  is  not  recognized.  The  patient,  usu- 
ally above  middle  age,  presents  himself  complaining  of  curvature  of 
the  penis  during  erection,  which  in  effect  is  a  chronic  chordee.  This 
often  has  progressed  until  coitus  is  impossible  before  the  surgeon 
is  consulted.  Syphilis,  alcohol,  rheumatism  and  gout  are  the  chief 
etiologic  factors  to  which  the  condition  is  attributed.  The  possible 
causal  relation  of  these  etiologic  factors  to  the  local  condition  is 
logical  enough,  but  it  is  not  easy  to  explain  why  the  pathologic 
process  should  localize  itself  in  the  erectile  tissue  of  the  penis, 
especially  where  the  process  is  more  or  less  diffuse.  Where  the 
condition  is  quite  circumscribed,  what  the  author  has  to  say  regard- 
ing a  general   arterial   disturbance   is   not   so   pertinent.     Old-time 

—  135  — 


IMPOTENCE  AND   STERILITY 

injury,  perhaps  long  forgotten,  and  infections  of  various  kinds, 
gonorrhea,  especially,  may  have  been  the  determining  cause,  espe- 
cially in  the  last  mentioned  class  of  cases.  In  the  diffuse  variety, 
and  probably  also  in  many  cases  of  the  circumscribed,  the  author  is 
confident  that  something  more  than  a  local  disease  exists.  In  brief, 
whatever  the  primary  etiologic  factors,  local  and  general,  may  be, 
the  penile  process  is  merely  the  local  expression  of  general  arterial 
disease. 

This  in  no  wise  lessens  the  importance  of  the  etiologic  factors 
usually  assigned  to  chronic  cavernositis  for,  as  is  well  known,  they 
bear  a  most  important  relation  to  the  general  condition.  Experience 
has  taught  the  author  to  look  for  evidences  of  general  arterio- 
sclerosis in  such  cases.  So  often  is  it  found  that  its  existence  may 
be  suspected  even  when  the  accessible  arteries  are  but  little,  if  at 
all,  involved.  In  gouty  "high  livers,"  who  are  not  far  advanced  in 
life,  incipient  arteriosclerosis  may  exist,  yet  no  cardiac  or  superficial 
changes  be  evident  as  yet.  Errors  in  diagnosis  by  internists  are 
frequent  because  of  this  fact. 

In  "type"  cases  of  the  condition  under  consideration,  cardio- 
vascular changes  are  found.  Arciis  senilis  may  be  present.  Time 
levels  symptomatic  distinctions  between  the  man  of  forty-five  or 
fifty  years  of  age,  in  whom  there  is  perhaps  nothing  but  slight 
hyper-vascular  tension ;  and  the  man  of  sixty  or  above,  with  pipe- 
stem  radials  and  temporals,  cardiac  changes  and  arciis  senilis. 

The  prognosis  of  cavernositis  is  in  general  unfavorable  so  far 
as  disappearance  of  the  deformity  is  concerned.  The  condition 
fortunately  is  painless  and  not  dangerous  to  life.  Occasional  cases 
are  met  with,  usually  of  the  circumscribed  variety,  in  which  the 
sclerotic  plaques  disappear,  whether  despite  or  because  of  treat- 
ment, the  author  does  not  venture  to  say.  Radium  is  promising  but 
little  that  is  definite  can  as  yet  be  said  about  it.  In  the  form  asso- 
ciated with  general  arteriosclerosis  thiosinamin  sometimes  seems  to 
be  useful. 

Certain  local  conditions  occasionally  are  attended  by  symptom- 
atic impotence.  Thus,  inflammation  of  the  testicles,  varicocele,  and 
tumors  of  the  testes  or  scrotum,  other  than  those  that  are  capable 
of  interfering  mechanically  with  the  act  of  copulation,  may  produce 
complete  impotence.  In  some  instances  this  is  due  to  reflex  inhibi- 
tion of  the  sexual  power,  while  in  others  the  condition  is  a  purely 

—  136  — 


IMPOTENCE   IN  THE   MALE 

mental  one,  resulting  from  the  moral  effect  of  the  knowledge  of  the 
existence  of  pathologic  conditions  of  the  sexual  apparatus.  In 
varicocele,  particularly,  both  elements  in  the  causation  of  impotence 
deserve  consideration.  There  is  a  lack  of  tone  —  in  fact,  a  marked 
debility  of  the  generative  apparatus  in  many  instances  —  and 
associated  with  this  enervation  there  is  profound  mental  disturbance, 
resulting  from  the  consciousness  that  the  sexual  organs  are  not 
healthy.  Syphilitic  orchitis  in  a  similar  manner  may  produce  impo- 
tence, and,  as  already  seen,  sterility.  If  this  condition  be  not  speed- 
ily relieved,  permanent  impotence  and  sterility  may  result  as  a 
consequence  of  changes  in  the  secretory  structure  of  the  testes 
incidental  to  the  pressure  of  the  syphilitic  neoplasm. 

Indulgence  in  alcohol  may  cause  impotence.  Various  other 
drugs  have  been  said  to  have  a  special  action  in  producing  impo- 
tence ;  but  a  certain  amount  of  skepticism  is  pardonable  in  this 
connection.  It  certainly  must  require  large  doses  of  the  various 
sedative  and  alterative  drugs  to  bring  about  this  condition.  Arsenic, 
antimony,  lead,  iodin,  camphor,  and  hasheesh  are  among  the  drugs 
that  are  said  to  produce  impotence.  Iodin  has  been  accredited  with 
the  power  of  producing  atrophy  of  the  testes.  The  author  does  not 
believe,  however,  that  a  single  authentic  case  can  be  produced  in 
which  such  atrophy  is  justly  attributable  to  the  use  of  this  drug. 
One  explanation  for  the  popular  idea  that  the  potassium  iodid  is 
capable  of  producing  atrophy  of  the  testes  is  that  certain  cases 
of  syphilitic  orchitis  have  been  insufficiently  treated  with  the  drug, 
or  treated  too  late.  Atrophy  of  the  testicle  has  resulted,  not  from 
the  drug,  but  from  pressure-innutrition  produced  by  syphilitic 
neoplasm  that  large  and  long-continued  doses  of  iodid  might  have 
removed  in  time  to  save  the  testis.  The  carbonated  waters  taken 
in  excess  are  said  to  produce  impotence.  The  author  regards  this 
as  a  pleasing  delusion  on  the  part  of  "men  about  town."  In  general, 
the  truth  probably  is  that:  1st,  narcotics  may  inhibit  sexual  power: 
2d,  any  powerful  drug  which  is  given  freely  enough  to  injure  the 
general  health  ma\-  produce  impotence. 

Vecki  claims  tliat  a  severe  cold  produces  impotence  by  inhibiting 
olfaction.  The  author  admits  the  clinical  fact,  but  believes  the  tem- 
l)orary  impotence  to  be  due  to  the  constitutional  effect  —  toxemia  — 
of  the  cold.  It  occurs  where  the  naso-})harynx  is  not  involved  and 
tlie  sense  of  smell  is  perfect. 

—  137  — 


IMPOTENCE  AND   STERILITY 

There  probably  is,  however,  some  association  between  the 
olfactory  and  sexual  function.  That  perfumes  and  personal  odors 
may  attract  or  repel  is  well  known.  Where  olfactory  impressions 
have  a  powerful  influence  over  sexual  desire,  atavism  probably  is  a 
sufficient  explanation. 

In  many  cases  of  impotence  it  is  impossible  to  attribute  the 
condition  to  any  particular  cause. 

Since  the  advent  of  the  X  Ray,  a  special  cause  of  impotence 
has  been  noted  in  the  disastrous  effect  of  the  ray  upon  the  structure 
and  function  of  the  testes.  Careless  operators  have  produced 
impotence  in  both  their  patients  and  themselves.  A  peculiar  effect 
of  the  X  Ray  occasionally  met  with  in  persons  exposed  to  its  action 
frequently  and  for  prolonged  periods  is  profound  anemia.  This 
may  be  a  factor  in  producing  impotence,  but  the  directly  destructive 
atrophy-producing  action  of  the  ray  upon  the  secretory  cells  of  the 
sex  glands  is  the  logical  explanation.  Sterility  may  result  without 
impotence.  Similarly,  the  female  may  be  sterilized  by  the  X  Ray. 
Obviously,  the  interstitial  or  hormone  producing  cells  —  cells  of 
Leydig  —  share  with  the  spermatic  secretory  epithehum  the  deleteri- 
ous results  of  the  ray.  This  is  an  important  factor  in  both  the 
sterility  and  impotence  that  result.  Proper  screening  of  the  sexual 
organs  and  filtering  of  the  ray  will  prevent  injury  from  the  X  Ray. 
If  the  action  has  not  been  too  severe  and  prolonged  and  further 
exposure  is  avoided,  the  structure  and  function  of  the  testes  possibly 
may  be  restored  to  a  greater  or  less  degree.  It  has  been  asserted 
that  radium  will  restore  the  integrity  of  gland  tissue  impaired  by 
the  X  Ray.  The  method  certainly  is  worth  a  trial.  Sex  gland  im- 
plantation quite  likely  would  be  of  service. 

TrKatmEnt.  —  The  treatment  of  impotence  may  be  divided 
into  (a)  moral,  (b)  medicinal  and  surgical.  The  latter  may  be 
subdivided  into:     (1)   general,   (2)   local. 

The  mainstay  of  treatment  in  false  or  nervous  impotence  con- 
sists of  psychotherapy.  In  fact,  there  is  no  form  of  impotence  in 
Vvhich  a  psychic  element  tliat  requires  correction  cannot  be  found. 
The  principal  requirement  is  the  restoration  of  the  patient's  self- 
confidence.  The  greatest  delicacy  and  judgment  are  necessary  in 
tlie  management  of  these  cases.  The  patient  should  feel  that  his 
physician  sym])athizes  with  him  in  his  apparent  affliction.  It  will 
not  do  to  laugh  at  his  ailment,  or  to  treat  it  lightly,  even  though 

—  138  — 


TREATMENT  OF  IMPOTENCE 

assured  that  his  impotence  is  imaginary  rather  than  real.  The 
patient  usually  is  comparatively  strong  and  healthy,  but  has  mastur- 
bated to  a  certain  extent  and  has  experienced  nocturnal  emissions 
with  greater  or  less  frequency.  Morning  erections  often  are  strong 
and  vigorous,  and  apparently  perfectly  normal.  Sexual  desire  is 
felt  and  may  be  present  in  an  exaggerated  form.  When  such  a 
])atient  attempts  intercourse,  erection  either  does  not  occur  at  all 
or  takes  place  in  a  spiritless  way  that  is  not  at  all  encouraging  to 
his  mind.  When  he  reflects  that  he  has  masturbated,  and  that  he 
has  experienced  an  occasional  nocturnal  emission,  with  perhaps 
other  little  symptoms  that  coincide  with  the  description  of  sperma- 
torrhea outlined  in  some  quack  treatise  or  other,  he  becomes  com- 
pletely demoralized.  So  careful  do  these  patients  study  quack 
literature,  and  so  firmly  convinced  of  their  impotence  do  they  be- 
come, that  it  often  is  absolutely  impossible  to  gain  their  confidence 
or  to  benefit  them  in  any  way  whatever.  A  symptom  that  greatly 
depresses  the  patient's  mind  is  the  escape  of  prostatic  fluid  and 
urethral  mucus  during  prolonged  and  vigorous  erection. 

An  efifort  shotdd  be  made  to  obtain  the  fullest  confidence  of 
such  individuals,  and  they  should  be  given  instruction  in  the  rudi- 
ments of  sexual  physiology.  In  the  majority  of  cases  they  may  be 
reasoned  out  of  their  perverted  and  pernicious  notions  regarding 
their  physical  condition.  ]\Iany  times  we  are  compelled  to  be  some- 
what disingenuous  in  our  management  of  the  case,  for,  the  patient's 
confidence  once  gained,  some  comparatively  trivial  local  or  general 
measure  may  cure  the  case,  providing  the  patient  himself  believes 
in  the  potency  of  the  treatment.  Above  all,  the  patient  should  be 
assured  that  his  sexual  apparatus  is  in  an  exceptionally  strong  and 
healthy  condition.  Alarriage  should  be  recommended  where  prac- 
ticable. Regarding  this  point,  however,  marriage  should  never  be 
advised  unless  the  occurrence  of  strong  and  vigorous  erections 
]:)rovcs  copulation  to  be  possible.  Even  under  these  circumstances, 
an  occasional  unfavorable  result  will  ensue,  because  of  persistent 
psychic  inhibition  of  erectile  power  at  the  time  copulation  is 
essayed.  In  cases  dependent  itpon  moral  or  mental  causes  pre- 
vailing when  copulation  is  attempted,  removal  of  the  circtmi stances 
that  produce  mental  depression  is.  of  course,  necessary.  The  ele- 
ments of  sexual  indifiference  due  to  mental  worry,  nervous  shock, 

—  139  — 


IMPOTENCE  AND   STERILITY 

fear  and  excessive  passion  may  be  amenable  to  correction.  Disgust 
with  the  partner  in  the  sexual  act  causes  impotence  which  is  irre- 
mediable when  the  unfavorable  conditions  are  continued.  It  may 
prevail  even  when  intercourse  with  a  new  partner  is  attempted. 
Sooner  or  later,  however,  the  case  usually  recovers  if  a  satisfactory 
sexual  "rearrangement"  is  consummated. 

In  those  cases  of  married  men  in  which  lack  of  affinity  is  the 
principal  cause  of  impotence,  medical  measures  are  likely  to  be  un- 
successful, although  some  form  of  local  stimulation  of  the  sexual 
organs  possibly  may  be  efficacious.  The  divorce-court,  however,  is 
a  better  and  more  logical  remedy  if  the  circumstances  imperatively 
demand  a  cure. 

In  many  instances  of  purely  nervous  impotence,  irritability  of 
the  prostatic  urethra  exists.  This  may  be  removed  in  the  majority 
of  instances  by  the  occasional  passage  of  a  cold  steel  sound.  If  the 
case  be  obstinate,  astringent  applications  may  be  made  by  means  of 
the  cupped  sound  or  deep  urethral  syringe.  The  prostate  or  seminal 
vesicles  sometimes  are  congested  or  chronically  inflamed.  Massage 
of  these  parts  relieves  this  condition.  The  psychrophor  or  cooling 
sound  sometimes  is  serviceable. 

In  cases  of  premature  ejaculation  success  often  may  be  at- 
tained by  a  second  attempt  at  copulation.  The  patient  should  be 
advised  to  avoid  excitement  during  intercourse.  Very  often  he 
may  succeed  in  delaying  orgasm  by  thinking  of  something  else 
beside  sexual  intercourse  at  the  time  of  its  performance.  Patients 
who  are  apprehensive  of  failure  should  be  advised  to  refrain  from 
intercourse  during  the  night,  and  to  attempt  it  only  in  the  early 
hours  of  the  morning. 

It  is  well  for  newly  married  men  affected  with  nervous  impo- 
tence to  confide  in  their  wives  and  explain  their  temporary  debility. 
The  patient  should  be  informed  that,  sooner  or  later,  he  will  have 
a  vigorous  erection  —  as  soon,  at  least,  as  the  novelty  of  the  situa- 
tion has  worn  off  and  his  timidity  has  been  allayed.  He  should 
be  instructed  to  immediately  take  advantage  of  the  situation,  when 
an  erection  does  occur,  and  ] perform  the  marital  act. 

Measures  of  a  general  and  hygienic  character  are  requisite, 
especially  in  tlie  management  of  cases  in  which  actual  structural 
disease  does  not  exist.  These  general  measures  involve  proper 
exercise,  diet,  baths,  ])ropcr  hours  of  sleep,  temperance,  or,  better, 

—  140  — 


TREATMENT  OF  lAfPOTENCE 

tola!  abstinence  in  the  matter  of  alcoholics  ar.d  tobacco,  and  free- 
dom from  care  and  worry  so  far  as  possible.  Such  measures  apply 
also  to  the  treatment  of  spermatorrhea,  a  condition  with  which 
impotence  very  often  is  associated. 

Cases  in  which  impotence  is  due  to  an  exhausted  condition  of 
the  sexual  apparatus  and  incidentally  of  the  general  nervous 
system,  with  in  some  instances  impairment  of  nutrition,  primarily 
require  complete  sexual  rest.  Occasional  or  so-called  moderate 
indulgence  is  not  to  be  thought  of  in  these  cases.  Perfect  conti- 
nence must  be  insisted  upon  for  the  time  being,  the  length  of  time 
varying  with  the  gravity  of  the  case.  It  is  unfortunate  that  the 
majority  of  patients,  and  particularly  voluptuaries,  are  loath  to 
accept  such  advice,  believing,  as  they  do,  that  by  means  of  aphro- 
disiacs their  virile  powers  should  be  restored  without  interfering 
with  the  indulgences  that  are  responsible  for  their  condition. 

Hammond's  remarks  upon  this  point  certainly  are  judicious. 
He  says : 

I  have  generally  found  that  in  those  cases  in  which  an  erection  suffi- 
cient for  intromission  does  not  take  place,  sexual  repose  for  about  a  year 
is  necessary.  Again,  the  age  of  the  patient  and  the  length  of  time  during 
which  the  condition  has  existed  are  factors  to  be  considered  in  determining 
the  question.  In  persons  over  forty,  and  in  wliom  the  condition  has  lasted 
six  months,  no  attempt  should  be  made  for  even  a  longer  period  than  a 
year.  With  every  unsuccessful  effort,  even  though  no  emission  occurs,  the 
nervous  excitability  is  still  further  lessened,  and  the  morale  materially 
lowered.  Generally  in  these  extreme  cases  there  is  no  difficulty  in  securing 
the  requisite  quiescence.  The  patient  is  fully  aware  of  his  inability,  and  is  in 
no  mood  to  undertake  what  he  knows  will  result  in  failure.  It  sometimes 
happens,  however,  that  masturbation,  with  the  erection  almost  nil  and  the  or- 
gasm imperfect,  is  practiced,  when  the  individual  finds  that  intercourse  is 
impossible.  It  is  in  this  respect  that  the  requirement  of  rest  must  be 
strictly    enjoined. 

Cases  in  which  the  principal  trouble  consists  of  premature 
ejaculation  and  feeble  erection  unquestionably  require  rest  for  a 
time ;  but  the  patient  is  likely  to  disregard  the  instruction  of  his 
medical  adviser  because  still  retaining  a  certain  degree  of  potency 
and  able  to  copulate  after  a  fashion  —  sufficiently  well,  at  least,  to 
make  the  indulgence  pleasurable.  In  cases  of  this  kind  the  patient 
should  be  informed  that  it  is  absolutely  impossible  to  benefit  his 
condition  iniless  he  will  consent  to  at  least  six  months'  continence. 

—  141  — 


IMPOTENCE  AND   vSTERIUTY 

The  moral  tone  and  mental  condition  of  the  patient  deserve 
special  consideration.  The  remarks  that  have  been  made  in  con- 
nection with  the  subject  of  masturbation  and  sexual  excess  are 
pertinent  in  these  cases.  Exercise,  intellectual  occupation,  and 
avoidance  of  all  sources  of  sexual  stimulation  must  be  insisted 
upon.  Where  practicable,  the  patient  should  be  advised  to  take 
a  change  of  scene ;  in  short,  to  cease  associations  that  tend  to 
excite  his  sexual  passion.  Traveling  —  and  particularly  a  sea- 
voyage  —  is  excellent  for  these  cases. 

Cold  shower-baths  or  plunge-baths  are  excellent  adjuvants  to 
the  general  treatment.  Delicate  patients  should  begin  by  a  course 
of  sponge-bathing.  Cold  sitz-baths  or  hot  and  cold  water  in 
alternation  are  useful.  Whatever  form  of  bath  be  selected,  it  should 
be  followed  by  brisk  rubbing  with  a  towel  or  flesh-brush.  Local 
douches  with  hot  and  cold  water  alternately  are  very  stimulating 
to  the  parts.  The  Turkish  bath  taken  in  moderation  and  followed 
by  the  cold  plunge  constitutes  one  of  the  best  of  general  tonics. 

The  diet  requires  some  attention.  It  should  consist  of  an 
abundance  of  easily  digestible  and  nutritious  food,  a  preponderance 
of  nitrogenous  elements  being  essential.  The  various  preparations 
of  malt  and  codliver  oil  are  excellent  means  of  improving  nutrition. 
An  abundance  of  good  rich  milk  and  cream  is  demanded.  Meats 
should  be  eaten  rare  and  should  contain  considerable  fat.  A 
moderate  amount  of  stimulants  is  often  useful.  Claret,  port, 
sherry  of  good  quality,  or  Dublin  stout  may  be  taken  with  the 
meals.  The  patient  should  be  advised  to  sleep  upon  a  hard  mattress 
with  light  covering,  this  measure  being  particularly  essential  if 
nocturnal  emissions  are  a  feature  of  the  case. 

Certain  internal  remedies  are  useful.  Contrary  to  the  general 
belief,  however,  not  only  are  there  no  specifics  for  impotence  — 
i.  e.,  no  drugs  that  can  be  depended  upon  to  so  stimulate  the  sexual 
apparatus  as  to  immediately  render  copulation  possible  —  but  there 
is  no  drug  known  to  science  that  can  be  relied  upon  for  the  restora- 
tion of  the  abused  and  maltreated  procreative  organs.  All  drugs 
and  systems  of  treatment  advertised  are  arrant  humbugs  and 
swindles.  Treatment  of  impotence  by  mail  is  a  delusion  and  a 
snare  set  for  the  credulous  and  ignorant  by  quacks.  Nearly  if 
not  quite  all  of  the  aphrodisiac  remedies  that  are  likely  to  be  useful 
in  impotence,  with  the  possible  exception  of  cantharides,  act  rather 

—  142  — 


TREATMENT  OF  IMPOTENCE 

as  general  restorers  of  nervous  energy  than  by  a  special  predi- 
lection for,  and  stinnilation  of,  the  sexual  apparatus.  Much  of  the 
reputation  of  various  drugs  depends  upon  the  moral  effect  of  their 
administration  in  cases  of  pseudo-impotence.  Nearly  all  the  cele- 
brated nostrums  and  quack  remedies  recommended  as  specifics  for 
impotence  have  become  celebrated  through  their  influence  upon  the 
minds  of  the  patients.  An  individual  who  is  impotent  because  of 
lack  of  confidence  in  his  virility,  is  likely  to  be  relieved  by  a  tritura- 
tion of  milk-sugar,  providing  he  has  confidence  in  the  efficacy  of 
the  placebo.  If  some  alleged  aphrodisiac  be  given,  it  is  likely  to 
acquire  an  undeserved  reputation  for  efiicacy.  The  best  remedy 
for  a  lack  of  tone  in  the  generative  apparatus  probably  is  iron.  The 
tincture  of  the  chlorid  may  be  given  in  doses  of  from  15  to  20 
drops  in  water,  three  times  daily,  after  meals.  The  pyrophosphate 
of  iron  perhaps  is  a  more  eligible  preparation  and  equally  effica- 
cious. It  should  be  administered  in  doses  of  from  5  to  10  grains 
thrice  daily.     It  may  be  advantageously  combined  with  strychnia. 

The  following  is  a  favorite  prescription  of  the  author's: 

IJ     Ferri  pyrophos gr.  v. 

Strychnine  sulph gr.  Voo 

Sodii  arsenit gr.  Voo 

M     Ft.  Caps. 

Sig.     Three  times  a  day  after  meals. 

Nux  vomica,  or  its  alkaloid,  strychnia,  has  an  excellent  reputa- 
tion in  the  condition  under  consideration.  Phosphid  of  zinc  and 
nux  vomica  may  be  given  in  combination.  The  following  is  an 
excellent  formula : 

IJ     Zinci    phosphidi    gr.  v. 

Ext.    nucis    vomicae gr.  xx. 

M     Ft.  pil.  No.  xl. 

Sig. :     One  three  times  a  day,  after  meals. 

Phosphorus  is  the  most  reliable  remedy  in  these  cases.  It  may 
be  given  in  solution,  as  a  tincture,  in  combination  with  zinc  as  in 
the  formula  just  given,  or  in  its  pure  state. 

A  pill  composed  of  '/^o  grain  of  phosphorus  and  ^ / ^  grain  of 
nux  vomica  is  an  excellent  combination.  The  principal  objection 
to  the  use  of  phosphorus  is  the  offensive  eructations  and  gastric 
disturbance  it  sometimes  produces.     The  mineral  acids  —  such  as 

—  143  — 


IMPOTENCE  AND   STERILITY 

dilute  phosphoric,  muriatic,  and  nitric  —  are  all  of  service.  Hypo- 
dermic injections  of  strychnia  often  are  useful,  a  single  daily  in- 
jection of  ^/ei  grain  of  the  sulphate  of  strychnia  being  more  effica- 
cious than  much  larger  and  more  frequent  doses  taken  per  orem. 

Opium,  the  bromids,  ergot,  digitalis,  gelsemium,  and  alcoholics 
all  have  their  uses  in  nervous  impotence. 

Cantharides  exhibits  a  more  marked  and  direct  immediate 
action  upon  the  generative  apparatus  than  any  other  aphrodisiac. 
It  should  be  given  cautiously,  however,  for  in  large  doses  it  may 
produce  inflammation  of  the  bladder  and,  coincidently,  severe 
strangury.  So  severe  are  its  effects  in  some  cases  that  obstinate 
priapism  and  insatiable  sexual  desire  may  occur,  perhaps  with 
inflammation  and  sloughing  of  the  penis  and  vesical  mucosa. 
Deaths  from  the  drug  have  been  frequently  observed.  In  impotence 
the  tonic  efi^ect  of  the  drug  should  be  aimed  at.  It  may  be  given  in 
from  10  to  15  drops  three  times  daily.  In  occasional  cases  a 
gradual  and  cautious  increase  of  the  dose  is  warrantable.  Thus, 
10  to  15  drops  three  times  a  day  may  be  given  to  commence  with, 
the  dose  being  increased  1  drop  each  day  until  slight  strangury  is 
produced,  when  it  should  be  discontinued.  If  there  has  been  no 
benefit  to  the  impotence  by  this  time,  further  administration  of 
the  drug  is  useless.  Damiana  is  a  much-vaunted  remedy  for  im- 
potence that  is  useful  to  a  certain  degree  as  a  tonic.  The  dose  is 
1  or  2  drams  of  the  fluid  extract  three  or  four  times  daily.  Both 
damiana  and  cantharides  will  be  reverted  to  in  a  subsequent 
chapter. 

Ergot  often  is  a  valuable  remedy  in  impotence,  particularly  in 
those  cases  in  which  there  seems  to  be  a  lack  of  tone  in  the  vascular 
supply  of  the  penis.  It  may  be  given  in  doses  of  10  to  20  drops, 
three  or  four  times  daily.  Certain  cases  of  impotence  have  been 
attributed  to  a  lack  of  tone  in  the  dorsal  vein  of  the  penis,  this 
condition  resulting  in  too  rapid  removal  of  the  blood  from  the  part 
during  erection.  Injections  of  ergotin  in  the  course  of  the  vein 
have  been  recommended  for  this  condition.  Ligation  or  resection 
of  the  vein  may  be  of  great  service.  According  to  Bartholow, 
jaborandi,  or  its  alkaloid,  pilocarpin,  is  an  active  aphrodisiac,  being 
indicated  in  cases  characterized  by  debility.  He  claims  that  it  is 
more  efficacious  than  any  other  agent.  The  dose  should  be  30 
minims  of  the  fluid  extract,  night  and  morning,  or  from  ^/r,  to  ^/g 

—  144  — 


TREATMENT  OF  IMPOTENCE 

grain  of  the  muriate  of  pilocarpin  thrice  daily.  The  author  beheves 
that  pilocarpin  is  of  some  vahie.  It  probably  acts  by  increasing 
testicular,  prostatic  and  seminal  vesicle  secretion.  Cimicifuga  also 
is  recommended  by  the  same  authority,  particularly  in  those  cases 
of  impotence  accompanied  by  spermatorrhea  of  long  standing,  with 
excessive  nervousness  and  anxiety  and  diminished  sexual  desire. 

In  cases  in  which  premature  ejaculation  from  sexual  hyperes- 
thesia and  active  secretion  of  semen  are  noied,  regular  intercourse, 
with  moderate  frequency,  and  the  administration  of  such  remedies 
as  potassium  bromid,  chloral-hydrate,  gelsemium,  and  ergot  often 
will  relieve  the  condition.  Potassium  bromid  is  the  most  popular 
sedative  for  sexual  hyperesthesia  or  excessive  desire,  so  often 
attended  by  partial  impotence.  Its  efficacy  has,  however,  been  dis- 
puted by  some  authors.  In  explaining  the  sources  of  fallacy  of 
those  who  disi)ute  the  anaphrodisiac  effects  of  the  bromids  Bartho- 
low  speaks  as  follows : 

1.  The  physiologic  eflfects  of  potassium  bromid  are  not  very  decided, 
and  are  readily  modified  by  any  local  disturbance. 

2.  Its  therapeutic  action  is  still  more  decidedly  influenced  by  local 
morbid  processes. 

3.  It  is  indicated  where  a  sedative  to  the  nervous  system  is  required : 
c.  g.,  in  insomnia,  too  great  reflex  excitability,  nervous  and  spasmodic  affec- 
tions of  the  larynx  and  bronchi,  sexual  excitement,  and  irritable  states  of 
the  sexual   organs. 

4.  It  will  be  effectual  in  the  foregoing  conditions,  in  proportion  to  the 
degree  in  which  structural  lesions  are  absent,  or,  in  other  words,  in  pro- 
portion to  the  degree  in  which  these  morbid  states  are  functional  rather 
than  organic. 

5.  These  conclusions,  the  result  of  observation  and  experiment,  afford 
us  a  satisfactory  solution  of  the  cause  of  failure  in  the  use  of  the  bromid  of 
potassium.  Sexual  excitement  in  mania  is  due,  as  shown  by  Schroeder  von 
der  Kolk,  to  structural  alteration  in  the  medulla  oblongata,  the  center,  ac- 
cording to  this  author,  of  the  sexual  impulse.  The  bromid  of  potassium  can 
have  no  influence  over  these  structural  alterations,  and  hence  cannot  control 
manifestations   of   sexual   excitement  depending  upon   them. 

With  increasing  exj)erience  in  endoscopy,  we  have  come  to  as- 
sign more  and  more  importance  to  morbid  conditions  of  the  colliculus 
seminalis  as  the  underlying  cause  of  perturbations  of  the  sexual 
function. 

Where  the  colliculus  is  inflamed,  endoscopic  application  of 
nitrate  of  silver  is  essential. 

—  145  — 


IMPOTENCE  AND   STERILITY 

The  local  and  general  application  of  electricity  in  its  various 
forms  is  very  useful  in  impotence.  It  is  especially  useful  in  the 
form  of  the  general  faradic  bath,  the  current  being  applied  while 
the  patient  is  in  a  tub  of  hot  water.  Its  application  should  be  fol- 
lowed by  a  cold  shower-  or  sponge-bath,  and  the  application  of 
static  electricity  or  the  high  frequency  current  to  the  spine,  particu- 
larly over  the  lumbo-sacral  region.  It  sometimes  is  beneficial  to 
apply  the  latter  form  of  electricity  to  the  perineum,  penis,  and 
testes.  Hammond  claimed  that  he  had  succeeded  by  means  of  the 
static  apparatus  in  restoring  sensibility  to  the  glans  penis  and  adja- 
cent tissues  when  galvanism  and  faradism  had  failed.  While  in- 
clined to  take  some  of  this  gentleman's  clinical  observations  cum 
grano  sails,  the  application  of  the  static  or  high  frequency  current 
in  this  manner  seems  rational  enough.  The  stimulating  effect  of 
static  electricity  upon  the  nervous  system  often  is  remarkable ; 
some  patients  say  that  it  acts  like  a  glass  of  champagne. 

The  faradic  current  in  moderate  strength  is  a  powerful  stimu- 
lant to  the  sexual  organs.  The  ordinary  sponge  electrodes  may 
be  used,  the  positive  pole  being  applied  to  the  lower  part  of  the 
spine  and  the  negative  to  the  penis  and  testes.  More  benefit,  how- 
ever, sometimes  is  to  be  derived  by  applying  the  negative  electrode 
to  the  genitals  and  the  positive  to  the  inner  aspect  of  the  thighs. 
A  wire  brush  electrode  may  be  used  instead  of  a  sponge,  this  being 
attached  to  the  negative  pole  and  passed  up  and  down  the  spinal 
column.  The  positive  pole  may  be  placed  first  upon  the  nucha  and 
afterward  upon  the  lower  portion  of  the  spine,  the  wire  brush  being 
passed  over  the  genitals.  More  or  less  pain  is  caused  if  the  current 
be  at  all  strong,  but  considerable  benefit  will  be  derived  from  its 
use.  The  circulation  and  nutrition  of  the  spinal  medulla  is  greatly 
improved,  and  the  vigor  of  the  sexual  nerves  is  necessarily  in- 
creased. The  application  of  the  wire  brush  to  the  genitalia  is 
es])ecially  serviceable  in  cases  of  impotence  that  appear  to  depend 
chiefly  upon  anesthesia  of  the  nervous  su])ply  of  the  glans  penis. 
The  galvanic  current  often  is  useful,  either  alone  or  in  combination 
with  the  faradic  current  on  alternate  days. 

The  high  frequency  current  has  proved  very  useful  in  the 
author's  hands.  It  may  be  applied  with  a  glass  electrode  directly 
to  the  ])rostatic  urethra. 

__  146  — 


TREATMENT  OF  IMPOTENCE 

One  of  the  best  stimulants  for  the  sexual  organs  is  the  faradic 
current  applied  directly  to  the  prostate.  /\n  insulated  sound  or 
bougie  is  attached  to  the  negative  ])ole  of  the  faradic  battery  and 
passed  down  to  the  prostatic  urethra.  The  positive  electrode  may 
be  applied  to  the  spine,  thighs,  hypogastrium,  or  genitals.  It  is  best 
applied  by  means  of  a  large  flat  sponge  electrode  to  the  lumbar 
region.  The  prostate  may  be  faradized  by  a  rectal  electrode 
attached  to  the  negative  pole.  The  galvanic  current  may  be  used 
in  a  similar  manner.  In  cases  in  which  the  trouble  appears  to 
depend  chiefly  upon  h3'peresthesia  of  the  prostatic  sinus  much 
benefit  often  may  be  derived  from  the  application  of  the  positive 
pole  of  the  galvanic  battery  to  the  prostatic  urethra.  A  local 
electric  bath  may  be  given  by  suspending  the  penis  and  testicles  in  a 
receptacle  of  warm  water,  the  negative  electrode  being  placed 
therein,  and  the  positive  held  in  the  patient's  hand.  In  applying 
electricity  directly  to  the  prostate  care  shovdd  be  taken  to  avoid  too 
powerful  currents  and  too  long  continuance  of  their  application. 
Inflammation  of  the  neck  of  the  bladder,  and  even  prostatitis,  are 
possible  sequences  of  carelessness  in  this  regard. 

In  the  milder  types  of  impotence  the  local  aj)plication  of  elec- 
tricity by  the  insulated  sound  in  combination  with  psychotherapy 
and  the  general  measures  that  have  been  suggested  rarely  will  fail 
to  restore  the  vigor  of  the  sexual  apparatus,  providing  the  patient 
is  faithful  in  his  treatment  and  devotes  sufficient  time  to  it.  It  is 
not  well  to  make  promises  regarding  the  length  of  time  necessary, 
and  the  patient  should  be  told  that  the  period  necessary  for  treat- 
ment can  be  determined  only  by  the  progress  of  the  case,  some 
cases  yielding  in  a  short  time,  while  others  require  a  protracted 
course  of  treatment. 

Prostatic  and  vesicular  massage  are  very  frequently  necessary 
in  the  treatment  of  impotence,  especially  in  post-infective  cases. 

It  should  be  remembered  that,  to  achieve  permanency  of  result, 
it  is  necessary  for  the  patient  to  continue  treatment,  and  to  abstain 
from  sexual  indulgence  for  son.ie  little  time  after  his  capacity  appar- 
ently has  been  restored. 

In  cases  of  premature  ejaculation  and  failure  of  erection  due  to 
extreme  sensitiveness  of  the  glans  penis,  circumcision  usually  is 
necessary,  as  most  of  these  cases  are  afifected  with  redundancy  and 

—  147  — 


IMPOTENCE  AND   STERILITY 

phimosis.  The  daily  application  of  cold  water  to  the  glans  is  an 
excellent  adjuvant  to  circumcision.  The  application  of  electricity 
by  the  galvanic  brush  or  the  high  frequency  current,  is  a  very  valu- 
able recourse.  Daily  applications  of  a  solution  of  tannic  acid  in 
alcohol,  or  of  aluminum  acetate,  are  serviceable  in  allaying  hyper- 
esthesia. 

The  application  of  stimulating  embrocations  to  the  penis  has 
been  recommended  for  impotence.  As  a  general  rule,  they  are 
worse  than  useless.  Sinapisms,  however,  as  recommended  by 
Roubaud,  may  be  of  temporary  service  in  some  instances,  by  tempo- 
rarily exciting  erectile  power  and  affording  a  permanent  cure  by  the 
psychic  efTect  of  the  erection.  The  irritation  produced  by  mustard 
is  sufficient  to  reflexly  excite  an  erection  in  the  majority  of  instances.- 
Care  should  be  taken  not  to  prolong  the  application,  lest  serious 
inflammation  result.  Cases  of  impotence  secondary  to  cerebral  or 
spinal  disease  should  not  be  subjected  to  much  special  treatment. 
All  therapeutic  efforts  should  be  directed  to  the  cure  or  improvement 
of  the  primary  condition.  As  improvement  of  the  condition  of  the 
brain  and  cord  occurs,  a  corresponding  improvement  in  sexual  vigor 
is  noted.  Some  remedies  for  impotence  are  injurious  in  cases  de- 
pendent upon  spinal  disease.  For  example,  spinal  excitants,  such 
as  phosphorus  and  strychnia,  should  not  be  given  in  locomotor 
ataxia,  as  they  are  likely  to  aggravate  the  organic  disease,  and  will  in 
no  way  benefit  the  impotence.  In  some  extreme  cases  of  sexual 
hyperesthesia,  the  application  of  silver  nitrate  to  the  deep  urethra 
by  means  of  the  deep  urethral  syringe  is  of  benefit. 

As  a  temporary  expedient  and  in  psychic  impotence,  the  applica- 
tion of  very  hot  water  to  the  penis  and  testes  just  prior  to  copulation 
often  is  efficacious. 

Most  of  the  deformities  of  the  sexual  apparatus  that  produce 
impotence  are  not  amenable  to  treatment.  Diagonal  section  of  the 
roof  of  the  contracted  urethra  may  benefit  some  cases  of  curvature 
of  the  penis.  Epispadias,  hypospadias,  and  certain  tumors  of  the 
penis,  scrotum,  and  testicles  are  amenable  to  treatment  by  the  knife. 

The  author  has  had  some  very  interesting  cases  showing  what 
sometimes  can  be  done  for  impotence  due  to  hypospadias.  The 
following  is  of  especial  interest : 

Case. — A  youth  of  seventeen  with  hypospadias  and  marked  curvature 
of  the  penis.     Erections  deformed  and  intromission  a  physical  impossibility. 

—  148  — 


i  Soil 


TREATMENT  OF  IMPOTENCE 


sin^ 


Subject   otherwise   normal.     The   pseudo-meatus    was   located   at   about   the 
middle  of  the  penis — antero-posteriorly. 

Operation :  1st  stage.  The  urethra  (corpus  spongiosum)  was  dis- 
sected away  from  the  body  of  the  penis  and  implanted  posteriorly,  the  new 
location  of  the  meatus  being  the  penoscrotal  angle.  All  connective  tissue 
bands  and  fibrous  contractures  were  divided  and  the  penis  straightened.  After 
healing  was  complete,  several  months  later,  a  new  penile  urethra  was  made 
from  a  flap  taken  from  the  scrotum.  A  practically  perfect  result  was  se- 
cured. The  author  assured  the  father  of  the  boy  that  there  was  one  espe- 
cially favorable  element  in  the  boy's  condition,  viz.,  that  he  could  not  con- 
tract gonorrhea,  because  of  the  fact  that  his  entire  penile  urethra  was  com- 
posed of  skin,  which  was  not  susceptible  to  gonococcal  infection.  To  the 
astonishment  of  all  parties  concerned,  the  boy  did  contract  a  severe  gonor- 
rhea within  a  year  after  the  operation.  Several  years  later  he  married  and 
had  a  normal  child.     He   still   is   sexually  normal. 

Resection  of  the  Vena  Dorsalis  Penis:  Like  all  other  surgical 
innovations,  ligation  and  resection  of  the  dorsal  vein  of  the  penis  for 
the  cure  of  impotence  became  a  fad.  The  "commercial"  surgeon 
hailed  the  new  operation  with  delight,  and  the  conservative  and 
conscientious  surgeon,  who  was  ready  to  grasp  at  any  straw  which 
offered  hope  of  relief  for  the  most  annoying  class  of  cases  that 
come  under  our  observation,  welcomed  the  operation  as  a  friend  in 
need.  As  is  usual  with  new  methods  of  treatment,  the  surgical 
fraternity  speedily  divided  into  two  camps,  viz. :  those  who  pro- 
claimed from  the  house-tops  the  infallibility  of  the  method,  and 
those  who  proclaimed  quite  as  vociferously  its  utter  worthlessness. 
The  gap  between  a  certain  prominent  American  surgeon,  whose 
patients  had  a  vigorous  priapism,  coming  on  before  they  left  the 
operating  table,  and  demanding  ice-packs  for  its  relief,  and  those 
who  condemned  the  operation  as  worthless,  was  a  wide  one.  There 
was,  however,  something  so  seductive  about  the  reports  of  the 
surgeon  with  the  priapism  patients,  especially  in  view  of  the  fact  that 
the  procedure  was  extremely  simple,  requiring  only  a  few  minutes 
under  local  anesthesia,  that  one  was  loth  to  give  ear  to  the  adverse 
critics.  Still  more  entrancing  was  the  simpler  "improved"  operation 
of  "subcutaneous  ligation  of  the  dorsal  vein." 

The  first  point  which  the  author's  experience  has  settled  to  his 
own  satisfaction  is  that  the  wide  variation  in  results  of  the  method 
obtained  by  different  operators  largely  is  explicable  by  a  wide  dif- 
ference of  technique.     As  the  object  aimed  at  is  purely  mechanic 

—  149  — 


IMPOTENCE  AND   STERILITY 

and  psychic,  the  average  of  results  should  be  the  same,  provided  the 
contemplated  mechanic  obstruction  in  the  vein  is  accomplished  by  it. 

The  operation  is  not  so  simple  nor  so  easily  performed  as  its 
more  sanguine  adherents  have  claimed.  The  rapid  operation  and 
the  subcutaneous  ligation  consist  in  most  cases  of  anything  but  liga- 
tion or  resection  of  the  vena  dorsalis  penis. 

The  dorsal  vein  proper  lies  beneath  the  fascia  propria  —  Buck's 
fascia  —  and  cannot  be  accurately  or  safely  ligated  or  resected  with- 
out careful  and  painstaking  dissection.  Subcutaneous  ligation  of  the 
vein  is  a  conception  of  anatomic  ignorance.  Ligation  of  the  super- 
ficial penile  veins,  however  large  and  prominent  they  may  be,  and 
essential  though  it  often  is  to  a  thorough  operation,  is  not  ligation 
of  the  vena  dorsalis  penis.  Granting  that  this  vessel  can  be  ligated 
without  an  oi)en  operation,  it  can  be  accomplished  only  by  wounding 
or  including  in  the  loop  of  the  ligature  other  important  vascular  and 
nerve  structures. 

The  relatively  prompt  effect  of  properly  performed  resection 
of  the  vena  dorsalis  penis  in  demonstrating  dynamic  sexual  capacity, 
through  purely  mechanic  circulatory  agencies,  necessarily  must  be 
a  powerful  factor  in  the  result.  Add  to  this  the  fact  that  the 
mechanic  conditions  secured  by  the  operation  practically  are  perma- 
nent in  quite  a  proportion  of  cases,  and  we  have  excellent  reasons 
for  faith  in  the  efficacy  of  the  operation.  Admitting,  for  the  sake 
of  argument,  that  its  eiTect  upon  the  circulation  of  the  penis  is 
merely  transitory,  this  would  not  count  against  the  operation  in 
purely  psychic  cases,  still  less  in  those  with  a  lesser  degree  of  psychic 
aberration.  The  suggestion  of  dynamic  capacity  has  done  its  work 
long  before  the  effect  of  the  operation  disappears. 

If  the  argument  that  the  effect  of  the  operation  is  purely 
psychic,  and  that  it  consequently  is  not  warrantable  in  the  treatment 
of  impotence,  is  permitted  to  liave  much  weight,  the  majority  of 
j^atients  would  be  discriminated  against.  Cases  of  impotence  in 
which  true  organic  ctiologic  factors  dominate  are  relatively  infre- 
c[uent,  and  in  many  of  those  of  an  organic  type,  there  are  certain 
factors  which  minimize  the  importance  of  impotence  per  se  —  e.  g., 
in  certain  cases  of  hypospadias,  epispadias,  etc. 

In  presenting  the  claims  of  the  operation  to  patients,  a  full  and 
frank   statement   of   i)()ssibilitics   and   ])robabilities   of   a   successful 

—  l.SO  — 


TREATMENT  OF  IMPOTENCE 

result  should  be  made,  with  due  and  thorough  consideration  of  the 
individual  merits  of  the  given  case.  With  the  psychic  element  in 
mind,  the  patient  should  be  encouraged  as  much  as  is  consistent. 

A  careful  and  exhaustive  inquiry  always  should  be  made  into 
the  circumstances  under  which  the  erectile  power  is  wanting,  with 
especial  reference  to  the  psychic  influences  dominating  at  the  time 
of  failure. 

As  to  whether  the  results  of  the  operation  substantiate  the 
claim  that  defective  erection  is  due  in  a  large  proportion  of  instances 
to  the  too  rapid  emptying  of  the  blood  from  the  dorsal  vein  of  the 
penis,  the  author  is  unable  to  say.  This  appears,  however,  to  be  a 
by  no  means  inconsiderable  factor  in  the  etiology  of  impotence,  and 
consequently  in  the  results  obtained  by  resection  of  the  vena  dorsalis 
penis.  It  must  be  remembered,  however,  that,  in  its  mechanic  re- 
sults, a  sluggishness  of  arterial  supply  would  in  efifect  be  precisely 
the  same  as  a  too  rapid  return  of  the  venous  blood  from  the  part. 
Defective  arterial  supply  probably  is  a  logical  explanation  of  quite 
a  proportion  of  cases  of  impotence,  and  consequently  of  the  benefits 
derived  from  operation. 

From  the  author's  experience  his  conclusions  in  brief  are : 

1.  Resection  of  the  vena  dorsalis  penis  in  the  treatment  of 
impotence  is  an  operation  requiring  accurate  anatomic  knowledge. 
It  cannot  be  done  subctitaneously  without  serious  injury  to  important 
parts  or  total  failure  of  the  operation. 

2.  The  operation,  while  not  essentially  dangerous,  is  neither 
so  simple  nor  so  easily  performed  as  some  have  claimed. 

3.  The  ligation  of  the  superficial  penile  veins  often  has  been 
performed  by  those  who  claimed  that  they  had  ligated  the  dorsal 
vein  proper.  This  operation  upon  the  superficial  veins  often  is 
essential  to  a  complete  operation,  but  when  performed  alone  is 
futile. 

4.  The  location  of  the  dorsal  vein  is  such  that  careful  and 
jxiinstaking  dissection  is  necessary  for  its  ligation  or  resection. 

0.  The  operation  is  beneficial  in  very  many  cases  on  strictly 
psychic  grounds,  but  this  does  not  militate  against  the  advisability 
of  its  performance.  The  important  thing  for  the  patient  is  a 
restoration  of  function. 

6.     In  some  cases  of  impotence  of  organic  origin  the  operation 

—  151   -- 


IMPOTENCE  AND   STERILITY 

is  not  to  be  thought  of,  but  in  quite  a  wide  range  of  cases  of  the 
kind  the  operation  is  successful,  firstly,  because  of  its  mechanic 
effect ;  secondly,  because  of  its  psychic  effect. 

7.  One  of  the  most  important  elements  in  the  cure  of  impo- 
tence by  a  properly  performed  resection  of  the  vena  dorsalis  penis 
is  the  demonstration  to  the  patient  of  dynamic  sexual  capacity 
through  purely  mechanic  circulatory  agencies. 

8.  Normal  erection  largely  revolves  around  the  maintenance 
of  equilibrium  between  the  efferent  and  the  afferent  blood  flow  in 
the  erectible  tissue.  Inefficient  intake,  or  excessive  outflow,  is  equally 
detrimental  to  erection.  Resection  of  the  dorsal  vein  of  the  penis 
aids  in  restoration  of  the  equilibrium. 

9.  The  mechanic  conditions  secured  by  the  operation  are 
permanent  in  quite  a  large  proportion  of  cases. 

10.  In  cases  of  complete  impotence  which  are  not  dependent 
upon  irremediable  local  causes  of  functional  disturbances  of  inner- 
vation, the  operation  apparently  is  successful  in  about  50  per  cent 
of  the  cases,  and  beneficial  in  probably  one-half  of  the  remainder. 

11.  In  by  far  the  majority  of  cases  of  impotence  that  come 
under  the  observation  of  the  surgeon,  a  trial  of  this  operation  is 
justifiable. 

The  cases  of  impotence  that  are  most  trying  to  the  physician 
are  those  met  with  in  individuals  at  about  middle  age  who  have  for 
many  years  indulged  excessively  in  sexual  intercourse.  Patients  of 
this  sort  consult  the  physician  in  the  hope  of  receiving  a  remedy 
that  will  enable  them  to  go  on  with  their  excesses,  and,  as  a  rule, 
they  do  not  attribute  their  condition  to  its  true  cause.  It  is  hard 
to  convince  such  patients  that  they  are  paying  for  their  early  in- 
dulgence, and  that  they  ought  not  to  expect  to  perform  the  sexual 
act  so  often  and  so  indiscriminately  as  when  they  were  young.  Such 
an  opinion  seldom  satisfies  them.  The  physician  is  consulted  by 
many  middle-aged  rones  who  complain  of  real  or  imaginary  sexual 
exhaustion,  spermatorrhea,  premature  old  age,  etc.,  and  these  cases 
certainly  are  difficult  to  manage.  If  the  patient  cannot  be  made  to 
understand  the  physiologic  conditions  involved  in  his  case,  and  the 
importance  of  resting  sexually  in  order  that  the  organs  involved  may 
recuperate  their  exhausted  vitality,  very  little  success  can  be  obtained 
by  treatment.  There  is  a  vulgar  notion  among  the  laity  to  the  effect 
that  a  man  is  capable  of  just  so  many  acts  of  sexual  indulgence 

—  152  — 


TREATMENT  OF  IMPOTENCE 

during  his  life-time,  and  that  he  may  either  distribute  these  acts  at 
proper  intervals  throughout  a  great  number  of  years  or  may  per- 
form them  within  a  few  years  early  in  life.  There  is  much  of  truth 
in  this,  for  it  is  a  cardinal  rule  that  overexcitement  of  any  function 
will  cause  loss  of  power.  The  man  that  copulates  with  moderation 
is  the  one  best  fitted  for  procreation,  because  he  is,  from  a  sexual 
point  of  view,  the  most  energetic.  It  is  a  well-known  fact  that  the 
male  population  of  the  Orient  become  impotent  at  a  very  early  age, 
earlier  than  any  other  race  of  men,  on  account  of  free  indulgence  of 
their  sexual  appetites.  For  that  matter,  among  all  nations  men  and 
women  alike  sufifer  from  premature  old  age  when  excessive  sexual 
indulgence  is  conjoined  with  a  life  of  indolence  and  ease.  The  man 
who  indulges  in  sexual  intercourse  most  frequently  in  his  youth  is 
the  one  w'ho  is  most  likely  to  become  impotent  or  sterile  when  he 
reaches  middle  age.  It  is  said  that  quite  a  proportion  of  Oriental 
males  become  impotent  at  the  age  of  from  30  to  40  years. 

^Moderation  in  sexual  intercourse  is  not  only  conducive  to  pro- 
longed virility,  but  to  longevity.  It  is  certain  that  many  cases  of 
neurasthenia  in  both  male  and  female  are  due  to  sexual  excess. 

The  treatment  of  the  class  of  cases  under  consideration  depends 
for  its  sticcess  mainly  upon  careful  instruction  of  the  patient  in 
sexual  physiology.  The  cause  of  his  disability  should  be  explained 
to  him,  and  he  should  be  assured  that  the  only  hope  of  restoration 
of  virility  and  of  its  perpetuation  lies  in  complete  rest  of  the  sexual 
function  for  a  prolonged  period,  with  moderate  indulgence  for  the 
rest  of  his  life,  after  his  capacity  has  returned.  In  conjunction  with 
these  moral  means  for  restoration,  the  remedies  and  local  measures 
already  recommended  may  be  employed  as  the  case  demands.  Care 
should  be  exercised  in  advising  prolonged  rest  of  the  sexual  function 
in  old  men.  Obstinence  sometimes  is  followed  by  permanent  sexual 
disability. 

Where  impotence  depends  upon  one  or  more  of  the  organic 
conditions  enumerated  in  connection  wuth  etiology,  the  cause  should 
be  dealt  with  upon  its  surgical  merits. 

Aspe;rmia. 

The  term  "aspermism,"  or  aspermia,  has  been  applied  to  some 
cases   in   which,   although   erections  are   normal   and   copulation   is 

—  153  — 


ASPERMIA 

performed  with  facility,  there  is  no  ejaculation  of  semen.  There 
may  or  may  not  be  sexual  desire.  A  peculiar  feature  of  these  cases 
is  that  the  patient,  although  unable  to  have  an  emission  during 
normal  intercourse,  invariably  acknowledges  the  occurrence  of 
voluptuous  dreams  attended  by  pleasurable  sensations  and  emission 
of  semen.  On  examination  the  urethra  will  be  found  to  possess  the 
usual  amount  of  sensitiveness  in  all  parts,  excepting  the  prostatic 
sinus,  where  there  apparently  is  complete  anesthesia. 

The  author  has  observed  several  cases  in  which  aspermism  was 
the  f ovmdation  of  sterility.    Two  of  these  are  of  particular  interest : 

Case  1. — A  healthy  man,  35  years  of  age,  who  had  never  had  any  ail- 
ment or  injury,  sought  advice  regarding  failure  of  emission.  The  patient 
stated  that  he  had  been  sexually  normal  until  within  a  year,  since  which  time 
he  had  found  it  impossible  to  have  either  orgasm  or  emission.  Sexual  desire 
still  was  normal  and  erection  perfect,  but  no  amount  of  duration  of  effort 
in  copulation  was  sufficient  to  bring  about  an  orgasm.  Sexual  intercourse 
never  had  been  indulged  in  to  any  great  extent,  even  before  any  abnormal- 
ity was  noticeable.  Erotic  dreams  and  nocturnal  emissions  were  quite 
troublesome.  This  case  finally  yielded  to  faradism  of  the  prostatic  urethra. 
The  treatment  was  directed  to  the  relief  of  the  evident  anesthesia  of  this 
part,  which  apparently  was  the  cause  of  the  aspermia. 

Another  very  interesting  case  recently  came  under  the  author's 
observation : 

Case  2. — A  young  man,  30  years  of  age,  with  the  following  history: 
He  had  masturbated  for  some  years,  beginning  at  the  age  of  fifteen.  For 
the  last  ten  or  twelve  years  he  had  had  intercourse  at  frequent  intervals, 
latterly  two  or  three  times  weekly.  He  never  had  been  able,  either  by 
masturbation  or  during  sexual  intercourse,  to  have  an  ejaculation  of  semen. 
The  act,  he  said,  was  pleasurable,  but  absolutely  unattended  by  anything 
like  orgasm  or  seminal  emission.  On  inquiry  he  stated  that  he  had  tired 
himself  out  in  the  attempt  repeatedly,  but  without  success.  He  was  aware 
that  it  was  not  the  fault  of  secretion,  as  he  stated  that  he  frequently  after 
intercourse  had  lascivious  dreams  with  copious  emissions. 

On  examination  the  sexual  organs  were  found  to  be  normal,  with 
the  exception  tliat  there  was  absolute  anesthesia  of  the  prostatic  sinus,  in 
which  nothing  was  found  on  endoscopy.  Sounds  produced  no  sensation 
whatever,  nor  was  a  strong  faradic  current  more  successful.  The  patient 
in  all  other  respects  was  perfectly  normal — indeed,  he  was  an  exceptionally 
robust  man.  He  stated  that  during  strong  sexual  excitement  there  escaped 
from  the  meatus  a  small  quantity  of  fluid,  which,  from  his  description, 
unquestionably  was  prostatic  secretion. 

Sexual  desire  was  marked,  which  made  his  condition  particularly  dis- 
tressing. He  stated,  however,  that  copulation  was  not  entirely  vmattended 
with   gratification,    else   he   would    not   have   had    intercourse   so    frequently. 

—  154  — 


IMPOTKXCE   AND    STKRILTTY 

Under  prostatic  massage  and  faradisni  of  the  prostatic  urethra, 
this  case  improved  so  that  scanty  emissions  occurred  during  copu- 
lation, but  he  never  fully  recovered. 

Ultzmann  related  some  very  typic  illustrations  of  aspermia. 

Roubaud  advanced  the  theory  that  aspermia  depends  upon 
spasmodic  contraction  of  the  muscular  fibers  about  the  mouths  of 
the  ejaculatory  ducts,  preventing  the  escape  of  the  semen  into  the 
prostatic  sinus.  This  view  hardly  is  in  accordance  with  the  phys- 
iology of  the  part.     Keyes  says,  anent  this  point: 

Were  there  desire  and  pleasure,  prostatic  mucus  would  be  secreted  in 
excess  and  would  be  thrown  out  by  ejaculation,  while  the  semen  proper 
would  collect  and  distend  the  seminal  vesicles  and  ducts  below  the  ejaculatory 
orifices,  and  would  escape  and  flow  away  from  the  meatus  with  the  re- 
laxation of  spasm  brought  about  by  the  fatigue  following  prolonged  sexual 
intercourse,  but  this  is  not  the  case ;  the  fault  is  evidently  in  the  nerves. 
There  is  no  pleasurable  sensation,  no  call  for  secretion  of  prostatic  mucus, 
nor  for  a  supply  of  spermatic  fluid.  There  is  anesthesia  of  the  prostatic 
sinus,  and  although  the  power  of  having  an  orgasm  and  ejaculation  remains, 
as  proved  by  dreams,  yet  there  is  some  connecting  link  missing  in  the  chain 
which  transforms  friction  of  the  glans  into  pleasure  at  the  prostate,  and 
finally   into    secretion   in   the   testicle. 

There  probably  is  not  only  anesthesia  of  the  floor  of  the  prostatic 
urethra,  but  a  lack  of  the  special  sensibility  of  the  nerves  of  the 
glans  penis  that  normally  is  acquired  during  erection.  It  is  possible, 
too,  that,  although  the  nerves  of  the  prostatic  sinus  are  normally 
sensitive,  the  nerves  of  the  glans  fail  to  appreciate  and  transmit 
pleasurable  sensations.  The  function  of  the  latter  nerves  perhaps  is 
inhibited  by  the  consciousness  of  the  patient  of  the  lack  of  sensibility 
in  the  glans.  During  sleep  inhibition  does  not  occur,  and  the  sub- 
conscious memory  of  normal  copulation,  of  which  the  patient  once 
was  capable,  is  sufficient  to  impart  a  pleasurable  sensation  and  re- 
flexly  produce  an  orgasm. 

Defective  secretion  is,  in  the  author's  opinion,  an  important 
factor  in  some  cases.  Perturbation  of  hormone  supply  may  be  an 
element  in  these  cases,  ^^'ith  increasing  faith  in  the  physiologic  im- 
portance of  the  sex  hormone,  the  author  inclines  to  the  belief  that  in 
many  cases  both  of  primary  and  secondary  impotence,  defective 
hormone  is  an  important  factor.  In  some  cases,  it  alone  may  be  the 
cause  of  the  condition.  Variation  in  sex  hormone  quality  probably 
is  the  explanation  of  the  wide  variation  in  primary  sexual  capacity. 

—  155  — 


TREATMENT    OF    ASPERMIA 

TRKATiMEA'T. — The  treatment  of  this  condition  generally  is  re- 
garded as  very  unsatisfactory.  Roubaud  reports  a  case  in  which 
blistering  the  perineum,  with  subsequent  application  of  powdered 
morphin,  produced  a  cure.  He  recommends  antispasmodics,  in  ac- 
cordance with  his  theory  of  the  pathology  of  the  disease.  Electricity 
in  the  form  of  the  static  and  faradic  currents  applied  to  the  spine 
and  genitalia — -especially  to  the  prostatic  urethra — would  appear  to 
be  the  most  rational  form  of  treatment,  and  has  been  moderately 
successful  in  the  author's  hands. 

Faradism  is  to  be  recommended  for  both  its  moral  and  physical 
effects.  A  strong  faradic  current  applied  to  the  prostate  sinus, 
daily  if  possible,  thrice  weekly  at  least  —  in  combination  with 
mildly  irritant  injections  into  the  prostate  from  time  to  time,  appears 
to  be  the  rational  indication.  Prostatic  massage  also  seems  to  be  a 
logical  measure. 

It  seems  to  the  author  that  in  some  of  these  cases  there  may 
exist  at  the  time  of  copulation  some  peculiar  inhibitory  mental  influ- 
ence that  prevents  culmination  of  the  sexual  act.  Mental  influences 
sometimes  have  this  effect  in  perfectly  healthy  individuals.  Once 
let  the  sexual  act  be  naturally  performed  in  these  cases  of  aspermism 
and  the  "spell"  is  likely  to  be  broken.  When  once  the  sexual  act  is 
co-ordinated  with  the  mental  elements  necessary  to  the  proper  per- 
formance of  the  sexual  function,  not  only  will  ejaculation  occur,  but 
the  impression  is  likely  to  be  a  permanent  one,  the  necessary 
sensibility  being  subsequently  called  forth  in  a  normal  manner  on  all 
proper  occasions.  The  prognosis  in  these  cases  usually  is  not  prom- 
ising. 

The  question  of  matrimony  is  important  in  cases  of  aspermia. 
As  the  matter  of  sterility  so  far  as  the  male  is  concerned  is  of  rela- 
tively little  importance,  provided  he  be  capable  of  performing  the 
sexual  act,  the  author  can  see  no  reason  why  the  patient  should  not 
marry,  particularly  as  marriage  is  likely  to  afford  the  mental  condi- 
tion and  the  environment  necessary  to  awaken  the  more  or  less 
dormant  sexual  sensibility.  A  frank  statement  of  conditions  of 
course  should  be  made  to  the  prospective  wife. 

Roubaud's  suggestion  of  the  use  of  antispasmodics,  on  the 
theory  of  the  dependence  of  the  disease  upon  muscular  contraction, 
seems  a  little  fanciful.     Inasmuch,  however,  as  antispasmodics  usu- 

—  156  — 


niPOTENXE   AND    STERILITY 

ally  are  sedative,  success  might  be  obtained  by  their  administration 
through  their  effect  upon  the  brain,  and  incidentally  the  production 
of  mental  calm  where  unfavorable  circumstances  of  disquietude  exist 
at  the  time  of  copulation. 

It  generally  is  supposed  that  it  is  necessary  for  the  semen  to 
distend  the  prostatic  sinus  in  order  that  orgasm  may  occur.  This 
may  be  true  of  individuals  who  never  have  had  an  emission  of 
semen,  but  that  it  is  not  true  in  general  is  shown  by  the  fact  that 
aspermics  —  /.  c,  individuals  who  expel  no  semen  whatever  — 
sometimes  have  an  orgasm  as  keenly  pleasurable  as  that  of  a 
healthy  individual.  Thus,  in  one  of  the  author's  cases  in  which  he 
removed  a  tuberculous  testicle,  the  remaining  epididymis  subse- 
quently became  occluded  from  epididymitis  and  chronic  thickening. 
There  was,  however,  a  restoration  of  i)reviously  impaired  power,  the 
patient  having  intercourse  regularly  and  experiencing  the  normal 
amount  of  pleasure  therein.  Never  since  the  involvement  of  the 
remaining  epididymis,  however,  has  he  had  an  emission,  even  of 
prostatic  fluid. 

Duration  of  the  Procrkativl;  Power. 

The  period  of  endurance  of  procreative  vigor  varies  with  the 
individual.  It  sometimes  is  preserved  to  very  old  age.  It  begins  at 
puberty,  growing  more  and  more  vigorous  as  time  goes  on,  until 
maturity,  when,  if  the  subject  has  not  indulged  in  vicious  habits,  the 
procreative  power  is  at  its  height.  It  remains  more  or  less  station- 
ary until  middle  life,  when  a  gradual  decline  is  noticed.  From  this 
time  on,  under  physiologic  conditions,  the  activity  of  the  procreative 
power  gradually  wanes  along  with  that  of  all  the  other  bodily  func- 
tions.    Fertility  probably  wanes  faster  than  physical  capacity. 

In  normal  women,  physical  capacity  is  coeval  with  life.  Fer- 
tility begins  with  menstruation  and  ceases  w'ith  the  menopause. 

The  author  recalls  a  very  peculiar  case  occurring  in  the  New 
York  Charity  Hospital  showing  that  sexual  congress  may  sometimes 
be  carried  on  by  the  female  under  extreme  difficulties : 

Case. — A  woman,  20  years  of  age,  with  complete  atresia  vaginae,  w-ho, 
strange  to  saj-,  nevertheless  led  the  life  of  a  public  prostitute.  The  external 
parts  were  perfectly  developed,  but  there  was  no  opening  whatever  corre- 
sponding to  the  normal  situation  of  the  vagina.    The  case  differed,  too,  from 

—  157  — 


DURATION  OF  THE  PROCREATIVE  POWER 

ordinary  atresia,  inasmuch  as  there  was  no  thickened  fibrous  cord  between 
the  bladder  and  rectum  such  as  is  ordinarily  met  with  in  occlusion  of  the 
vagina,  and  which  represents  the  walls  of  the  canal  that  have  become  fused 
together.  When  the  index  finger  of  each  hand  was  introduced  into  the 
bladder  and  rectum  respectively  nothing  could  be  felt  between  them  but  the 
walls  of  these  viscera.  Neither  uterus  nor  ovaries  could  be  detected.  How 
this  woman  copulated  is  a  mystery.  There  was  no  evidence  of  pederasty. 
Whatever  the  circumstances  may  have  been,  the  woman  certainly  was  not 
aware  of  her  condition,  but  supposed  that  she  had  been  performing  the  act 
of  copulation  like  other  women.  The  urethra  was  very  commodious,  and  it 
is  possible  that  it  had  been  utilized  as  a  sexual  way.  Such  cases  have  been 
reported. 

It  is  safe  to   formulate  the   following  cardinal  principles   for 
the  laity,  viz. : 

1.  Conservation  of  bodily  vigor  conserves  procreative  vigor. 
The  better  the  care  of  the  body,  the  better  the  likelihood  of 
the  procreative  capacity  being  carried  into  the  later  years 
of  life  and  the  better  the  quality  of  children  born. 

2.  Certain  persons  primarily  are  more  virile  than  others.  The 
standard  must  be  individual. 

3.  Men  of  middle  age  or  over,  who  expect  as  much  of  their 
procreative  function  as  in  early  manhood,  merely  display 
their  ignorance  of  physiology. 

4.  Men  who  have  abused  or  excessively  used  their  procreative 
function  in  youth  and  early  manhood  may  expect  to  "pay 
the  fiddler"  at  middle  life.  One  cannot  "eat  his  cake  and 
have  it." 

5.  The  man  who  indulges  to  excess  in  alcoholics  also  may  ex- 
pect to  "pay  the  price"  sooner  or  later. 

6.  Persons  who  have  had  deep-seated  gonorrhea  or  severe 
syphilis  may  expect  early  waning  or  absolute  destruction 
of  the  procreative  power. 


158 


CHAPTER    VIII. 

Sterility  and  Impotence  in  the  Female. 

Fertilization. — For  the  purposes  of  this  volume  the  process 
of  fertihzation  may  be  reduced  to  very  simple  terms.  The  condi- 
tions necessary  are:  1st.  'J^he  ])roduction  of  spermatozoa  by  the 
male  and  of  an  ovvile  by  the  female.  2nd.  The  discharge  of  the  one 
from  the  testis  and  of  the  other  from  the  ovary.  3rd.  The  contact 
in  the  female  sexual  tract  of  a  single  spermatozoon  with  an  ovule ; 
this  probably  usually  occurs  in  the  uterine  end  of  the  Fallopian  tube. 
4th.  The  chromosomes  of  both  ovum  and  spermatozoon  must  be 
healthy.  5th.  There  must  be  no  essential  primary  incompatibility 
of  the  ovule  and  the  spermatozoon.  6th.  The  tubal  and  uterine 
mucosa  must  be  normal,  meaning  that  there  must  be  no  secretion 
of  the  membrane  that  is  deleterious  to  the  vitality  of  either  ovum  or 
spermatozoa,  and  no  condition  of  the  mucosa  that  will  prevent 
lodgment  and  growth  of  the  ovum. 

It  is  evident  that  there  are  numerous  conditions  which  may : 
1st.  Impair  the  primary  vitality  of  the  ovule  and  spermatozoon. 
2nd.  Prevent  the  meeting  of  the  two  elements  at  the  proper  time  and 
place.  3rd.  Impair  the  fitness  of  the  soil  in  which  the  two  elements 
meet. 

It  is  obvious  that  nutritive  perversion  of  the  parental  chromo- 
somes and  obstacles  to  their  meeting  may  occur  in  either  party  to 
the  sexual  act. 

Statistics  show  that  about  one  in  eight  marriages  are  unpro- 
ductive. As  already  seen,  a  portion  of  the  responsibility  for  sterility 
must  be  borne  by  the  male.  Most  of  it,  however,  justly  or  unjust- 
ly,— unjustly,  of  course,  where  the  fault  is  due  to  gonorrhea  con- 
tracted from  the  husband — falls  upon  the  female. 

ETioi<or.Y. — The  causes  of  sterility  in  the  female  are  very  nu- 
merous.    In  general,  they  are  as  follows : 

1.  Inability  to  receive  the  semen.  (Impotence  from  various 
causes.) 

—  159  — 


IMPOTENCE  AND   STERILITY 

2.  Destruction  of  spermatozoa  by  morbid  secretions  of  the 
female  sexual  tract. 

3.  Inherent  or  acquired  resistancy  to  impregnation. 

4.  Failure  to  ovulate. 

5.  Inability  to  develop  the  ovum  after  fecundation. 
Sterility  in  the  female  may  be  classified  as : 


1. 

Intrinsic    or    "facultative." 

2. 

Relative,  e.  g.,  one  child  steril- 

ity. 

3. 

Artificial,    t.    e.,   incidental   to     I 

a. 
b. 
c. 

Surgical    operation. 
Religious    ceremony. 
Removal   for   social  protection. 
4.     Accidental,    i.    e.,    from   disease 
or  accident. 

Etiology  in  detail : 

Impotence,    i.  c,  mechanic  obstruction  to  coitus. 
Idiopathic  vaginismus. 
Inflammation   of   the   sexual  tract. 

Uterine  myoma ;  uterine  prolapse,  flexions  and  versions ;  lacerations,  in- 
durations and  new  growths  and  strictures  of  the  cervix ;  congenital  or 
acquired  atresia  and  new  growths  of  the  vagina ;  imperforate  hymen ; 
infantile  uterus,  and  undeveloped  ovaries ;  dysmenorrhea ;  ovarian  and 
pelvic  tumors ;  stenosis  of  the  Fallopian  tubes ;  vulvar  tumors  and  trau- 
matisms;  anchylosis  of  the  hip  joints. 

These  are  the  principal  mechanic  causes  of  sterility  in  women. 
Parotiditis  with  secondary  infective  inflammation  and  atrophy  of 
the  ovaries  is  an  occasional  cause  inhibiting  the  production  of  the 
ovule. 

Gonorrhea  acts  in  the  production  of  sterility  in  numerous  ways, 
viz.:  1.  Producing  an  unhealthy  state  of  the  mucosa  of  the  vagina, 
uterus  and  tubes,  which  renders  the  soil  unfit  for  the  growth  of  the 
ovum.  2.  Producing  a  toxic  secretion  which  impairs  the  vitality  of 
the  ovule  and  spermatozoa  or  kills  them  completely.  3.  Producing 
mechanic  obstacles  to  coitus.  4.  Producing  mechanic  obstruction 
within  the  utero-vaginal-tubal  tract,  thus  preventing  the  downward 
passage  of  the  oviun  and  the  upward  passage  of  the  spermatozoa. 
5.  Producing  pelvic  peritonitis  with  adhesions  which  displace  the 
ovary,  tube  or  uterus — one  or  all — or  constrict  the  tube.  6.  Infect- 
ing and  damaging  the  ovary. 

The  vitality  of  the  ovule  is  impaired  {i.  c,  the  quality  and 
quantity  of  sex  hormone  produced  in  the  ovary  and  supplied  to  the 

—  160  — 


STERILITY    AND    IMPOTENCE    IN    THE    FEMALE 

ovule  are  injuriously  altered)  by  numerous  constitutional  condi- 
tions, such  as  primary  lack  of  vitality  on  the  part  of  the  female, 
anemia  and  debility  from  any  cause,  and  various  toxemias,  such  as 
those  produced  by  malaria,  lead  poisoning,  mixed  infection  from 
tuberculosis,  fevers,  alcoholism  and,  most  important  of  all,  syphilis. 
Obesity  produces  debility  as  well  as  a  mechanic  obstacle  to  fertiliza- 
tion. Cross  breeding,  as  of  negro  and  white,  lessens  fertility  and 
produces  relative  sterility.  Consanguineous  marriage  is  likely  to 
have  a  similar  effect,  merely  because  of  the  fact  that  selective  mat- 
ing is  not  practiced.  It  is  obvious  that  perverted  hormone  pro- 
duction may  be  secondary  to  any  local  disease  of  the  sexual  organs. 

In  some  women  the  cause  of  sterility  probably  is  a  primary  in- 
herent incapacity  for  fertilization.  It  is  to  be  remembered,  how- 
ever, that  sterility  in  such  cases  may  be  only  apparent,  not  real. 
Proper  mating  might  correct  it.  That  sterility  may  be  hereditary 
seems  at  first  sight  to  be  something  of  an  "Irish  bull."  Relative 
sterility,  however,  may  be  transmitted  and  eventually  end  in  com- 
plete sterility. 

The  female  most  often  fails  to  receive  the  semen  from  default 
ujion  her  own  part.  Various  local  conditions  may  prevent  her  from 
having  coitus.  These  conditions  comprise  such  congenital  or  ac- 
quired malformations  or  imperfections  of  development  as  prevent 
penile  intromission.  In  these  rare  cases  the  female  is  impotent  as 
well  as  sterile.  Impotence  in  the  female  may  be  due  to  incapacity 
for  the  complete  performance  of  the  sexual  act.  She  may,  how- 
ever, nevertheless  be  capable  both  of  insemination  and  impregnation. 

Frigidity — /.  c,  absence  of  sexual  desire  or  aversion  to  its  per- 
formance— and  absence  of  orgasm  constitute  one  variety  of  female 
"impotence."  Many  women  never  experience  the  slightest  degree  of 
voluptuous  excitement  during  cohabitation,  yet  they  are  fruitful  and 
bear  children.  It  has  been  held  that  the  erectile  structures  of  the 
genital  organs  become  turgid  even  in  this  class  of  cases,  just  as  it 
occurs  in  the  male,  without  orgasm;  but  this  is  doubtful.  Orgasm 
is  necessary  to  the  normal  performance  of  the  sexual  act  in  the 
female  as  well  as  in  the  male,  and,  while  conception  may  occur  with- 
out it,  it  is  the  exception  rather  than  the  rule,  be  the  orgasm  ever 
so  slight.  The  orgasm  in  the  female  must  subserve  some  physiologic 
purpose,  which  puri)ose  must  be  the  correlative  of  the  orgasm  in  the 
male.    The  male  orgasm  being  of  an  expulsive  character,  it  follows 

—  161  — 


IMPOTENCE  AND  STERILITY 

that  the  female  orgasm  nmst  be  for  the  purpose  of  furthering  the 
reception  of  the  semen — possibly  by  favoring  the  formation  and 
expulsion  onto  the  surface  of  the  cervical  mucosa,  of  a  secretion 
which  favors  vitality  and  activity  of  the  spermatozoa. 

Certain  observers  have  described  the  peculiar  behavior  of 
the  uterus  during  orgasm.  The  organ  appears  to  assume  a  more 
perpendicular  position,  and  sinks  lower  in  the  pelvis ;  the  os  uteri 
becomes  softer ;  the  "labia"  of  the  uterus  alternately  project  and  re- 
tract in  such  a  manner  as  to  produce  a  "suction"  effect.  These 
phenomena  are  accompanied  by  the  emission  of  a  clear,  sticky 
mucus.  Granting  the  occurrence  of  these  phenomena  in  the  cases 
observed,  they  should  occur  in  all  cases  where  there  is  a  normal 
orgasm  and  also  to  a  greater  or  less  degree  in  all  females  to  whom 
sexual  congress  is  in  any  degree  pleasurable. 

That  more  or  less  softening  of  the  cervix  and  a  flow  of  mucus 
occurs  the  author  believes,  beyond  this  he  is  skeptical. 

Acton  states  that  it  is  his  belief  that  the  majority  of  women  do 
not  experience  sexual  desire.     He  expresses  his  opinion  as  follows: 

I  should  say  that  the  majority  of  women  (happily  for  society)  are  not 
very  much  troubled  with  sexual  feeling  of  any  kind.  What  men  are  habitu- 
ally, women  are  only  exceptionally.  It  is  too  true,  I  admit,  as  the  divorce- 
courts  show,  that  there  are  some  few  women  who  have  sexual  desires  so 
strong  that  they  surpass  those  of  men,  and  shock  public  feeling  by  their 
consequences.  I  admit,  of  course,  the  existence  of  sexual  excitement  ter- 
minating even  in  nymphomania,  a  form  of  insanity  that  those  accustomed  to 
visit  lunatic  acylums  are  fully  conversant  with ;  but,  with  these  sad  exceptions, 
there  can  be  no  doubt  that  sexual  feeling  in  the  female  is,  in  the  majority 
of  cases,  in  abeyance,  and  that  it  requires  positive  and  considerable  excite- 
ment to  arouse  it  at  all ;  and  even  if  aroused  (which  in  many  instances  it  can 
never  be)  it  is  very  moderate  compared  with  that  of  the  male.  Many  per- 
sons, and  particularly  young  men,  form  their  ideas  of  women's  sensual 
feelings  from  what  they  notice  early  in  life  among  loose,  or,  at  least,  low  and 
vulgar  women.  There  is  always  a  certain  number  of  females  who,  though 
not  obtensibly  in  the  ranks  of  prostitutes,  make  a  kind  of  trade  of  a  pretty 
face.  They  are  fond  of  admiration,  they  like  to  attract  the  attention  of 
those  immediately  above  them.  Any  susceptible  boj'  is  easily  lead  to  be- 
lieve, whether  he  is  altogether  overcome  by  the  siren  or  not,  that  she,  and 
therefore  all  women,  must  have  at  least  as  strong  passions  as  himself.  Such 
women,  however,  give  a  very  false  idea  of  the  condition  of  female  sexual 
feeling  in  general.  Association  with  the  loose  women  of  the  London  streets 
in  casinos  and  other  immoral  haunts  (who,  if  they  have  not  sexual  feeling, 
counterfeit  it  so  well  that  the  novice  does  not  suspect  but  that  it  is  genuine) 
seems  to  corroborate  such  an  impression,  and,  as  I  have  stated,  it  is  from 

—  162  — 


STERILITY    AND    lAIPOTENCE    IN    THE    FEMALE 

these  erroneous  notions  that  so  many  unmarried  men  think  that  the  marital 
duties  they  will  have  to  undertake  are  beyond  their  exhausted  strength, 
and   for  this  reason  dread  and  avoid  marriage. 

Married  men,  medical  men.  or  married  women  themselves  would,  if 
appealed  to.  tell  a  very  dififerent  tale,  and  vindicate  female  nature  from  the 
vile  aspersions  cast  on  it  by  the  abandoned  conduct  and  ungoverned  lusts 
of  a  few  of  its  worst  examples. 

One  would  infer  from  Acton's  opinion  that  frigidity  is  the  nor- 
mal and  ])hysiologic  condition  of  the  woman.  \\'hile  ready  to  ac- 
<:e\A  the  statement  that  a  large  proportion  of  married  women  do  not 
exiperience  sexual  desire,  the  author  does  not  behevc  that  their 
frigidity  is  natural,  but  holds  that  it  usually  is  due  to  mistreatment 
on  the  ])art  of  the  husband.  The  average  man  when  entering  upon 
the  matrimonial  state  gives  very  little  consideration  to  the  question 
of  reci])rocal  pleasure.  A  virtuous  woman  primarily  entertains  an 
aversion  for  sexual  intercourse,  which  is  both  unesthetic  and  pain- 
ful in  the  beginning,  and  shrinks  from  it  with  becoming  modesty 
and  physical  fear.  This  condition  of  mind  usually  is  by  no  means 
improved  by  the  conduct  of  the  husband,  whose  sole  idea  is  to  obtain 
gratification,  irrespective  of  the  feelings  of  his  wife.  For  a  time 
he  is  perfectly  satisfied  with  his  matrimonial  relations  because  of 
their  novelty.  As  soon  as  this  wears  off.  however,  he  begins  to 
recall  past  experiences,  and  finds  fault  with  his  wife  for  her  lack 
of  reciprocity.  By  this  time,  unfortunately,  the  disgust  and  dread 
of  the  marital  act  that  have  been  inspired  by  the  brutality  of  the 
husband  have  become  a  ])art  of  the  woman's  very  existence,  and 
she  usually  is  ever  afterward  absolutely  frigid.  Having  become 
satiated  and  disgusted  with  the  marriage-relation  the  husband  is 
likely  to  seek  elsewhere  for  that  of  which  he  has  been  deprived 
through  his  own  mismanagement.  It  is  the  author's  opinion  that 
in  most  instances  of  frigidity  in  married  women  the  difficulty 
would  have  been  obviated  and  the  woman  would  have  become,  after 
a  time,  ]:)erfecth-  nattiral  in  respect  to  the  sexual  ftinction  if  the 
husband  had  been  more  intelligent  and  considerate.  It  is  by  no 
means  the  cx-roitc  alone  who  is  open  to  impeachment.  The  in- 
experienced man  often  is  more  at  fault,  through  ignorance,  than 
the  man  of  the  world  who,  perhaps,  has  done  more  than  his  share 
in  educating  women  in  sexual  love. 

The  old  adage  that  "familiarity  breeds  contempt"  is  an  excellent 
one  as  applied  to  matrimonial  infelicity.     The  divorce-cotirts  speak 

—  163  — 


IMPOTENCE  AND   STERILITY 

volumes  with  respect  to  inharmonious  sexual  relations  of  married 
persons.  Ignorance  on  the  part  of  the  woman,  brutality  or  igno- 
rance on  the  part  of  the  husband,  and  perhaps  in  some  instances 
excessive  indulgence  on  the  part  of  both  —  this  latter  bringing 
satiety  and  physical  ills  in  its  train  —  are  responsible  for  many  of 
the  cases  that  are  brought  all  too  prominently  before  the  gaze  of  a 
patient  and  long-suffering  public. 

The  prevalent  custom  of  married  people  occupying  the  same 
bed  is  the  cause  of  more  instances  of  lack  of  harmony  in  sexual 
matters,  and  incidentally  of  more  cases  of  sexual  excess,  than 
anything  that  could  be  mentioned.  It  certainly  tends  in  many 
instances  to  lessen  the  mutual  respect  of  married  couples,  and  to 
pall  the  attractiveness  of  the  matrimonial  state.  If  married  persons 
occupied  separate  apartments  the  novelty  of  matrimony  would 
not  be  likely  to  wear  away,  and  our  divorce-courts  would  be  shorn 
of  a  large  proportion  of  their  cases. 

As  already  indicated,  certain  mental  conditions  modify  the 
sexual  passion  in  women.  It  certainly  would  be  too  much  to  expect 
a  refined  woman  to  be  possessed  of  sufficient  animal  propensities 
to  be  able  to  display  a  genuine  passion  for  one  for  whom  she  has 
an  aversion.  Once  let  a  woman  —  however  passionate  naturally  — 
experience  a  feeling  of  disgvist  or  hatred  for  her  husband,  and  it 
is  probable  that  she  could  not  exhibit  genuine  sexual  passion  if 
she  would.  It  certainly  is  true  that  some  women  are  extraordinarily 
passionate  with  certain  individuals,  while  absolutely  frigid  with 
others.  This  is  well  illustrated  in  the  case  of  the  average  prostitute, 
whose  passion  in  her  strictly-business  relations  is  more  often 
assumed  than  real,  but  who  nevertheless  usually  has  a  favorite  lover 
who  certainly  has  no  cause  for  complaint. 

Apropos  of  inharmonious  conjugal  relations  there  is  another 
circumstance  that  often  explains  the  frigidity  exhibited  by  married 
women.  Many  women  are  allowed  to  become  mere  household 
drudges,  and  become  so  exhausted  physically  that  it  is  hardly  fair 
for  their  husbands  to  expect  any  reciprocity  upon  their  part. 
That  the  tendency  of  hard  labor  is  to  divert  the  nervous  energies 
from  the  sexual  apparatus  is  as  true  of  the  female  as  of  the  male. 

Many  women  are  restrained  from  the  exhibition  of  sexual 
passion  by  the  fear  of  conception,  their  apprehensions  being  aug- 

—  164  — 


STERILITY    AND    IMPOTENCE    IN    THE    FEMALE 

mented  by  the  popular  and  to  a  certain  extent  justifiable  notion 
that  the  danger  of  impregnation  is  proportionate  to  the  amount  of 
passion  exhibited  by  the  woman. 

We  have  seen  that,  in  order  that  impregnation  may  occur,  it 
is  necessary  that  Hving  spermatozoa  should  come  in  contact  with 
a  mature  healthy  ovule  at  some  point  above  the  uterine  cervico- 
corporeal  junction,  and  further  that  there  are  many  local  conditions 
that  prevent  this  meeting,  even  though  the  sexual  act  be  normal. 
It  must  be  understood  that,  while  women  under  such  circumstances 
are  dynamically  sterile,  they  are  not  potentially  so. 

The  conditions  that  interfere  with  the  normal  development  of 
the  ovule  are  a  terra  incognita  to  science.  It  is  probable  that  many 
immature  ovules  escape  prematurely  from  healthy  Graafian  follicles 
from  one  cause  or  another.  On  the  other  hand,  they  may  be  devital- 
ized by  disease.    In  either  event  they  are  incapable  of  impregnation. 

Defective  or  vitiated  hormone  supply  may  have  much  to  do 
with  primarily  imperfect  development  of  the  ovule. 

It  is  not  necessary  that  the  ovaries  should  be  healthy,  however, 
in  order  that  conception  may  occur.  Women  with  extensively  dis- 
eased ovaries  sometimes  conceive  and  bear  healthy  children.  If  a 
single  Graafian  follicle  be  healthy  and  there  is  nothing  to  prevent 
the  ovule  and  spermatozoa  coming  together,  conception  may  occur. 
On  the  other  hand,  a  healthy  mature  ovule  may  be  formed,  and 
many  healthy  ovules  be  discharged  from  the  ovary  from  time  to 
time,  but  fail  to  reach  the  uterine  cavity.  Inflammatory  affections 
of  the  ovary  involving  thickening  of  the  walls  of  the  Graafian 
follicles  may  prevent  healthy  ovules  from  leaving.  A  healthy  ovary 
may  be  so  bound  down  by  surrounding  inflammation  that  the  ovules 
cannot  escape.  Other  conditions  that  are  especially  fatal  to  the 
physiologic  purpose  of  the  ovule  are  diseases  of  the  Fallopian  tubes, 
adhesions  of  the  fimbriae  to  the  ovary,  and  uterine  disease  producing 
closure  of  the  uterine  extremities  of  the  tubes. 

Granting  that  conception  has  occurred,  the  uterus  may  be  so 
diseased  that  it  can  not  furnish  a  suitable  nidus  for  the  reception, 
attachment,  and  subsequent  development  of  the  ovum.  The  cor- 
poreal endometrium  is  a  highly  organized  structure  and  often 
the  seat  of  pathologic  conditions.  Gestation  demands  that  it  be 
healthy.  Intra-uterine  disease  is  so  frequent,  however,  that  good 
authorities  consider  it  to  be  the  cause  of  sterility.     Women  thus 

—  165  — 


IMPOTENCE   AND    STERILITY 

diseased  are  perfectly  capable  of  conception;  but,  the  uterine 
mucous  membrane  being  unfitted  for  the  attachment  and  develop- 
ment of  the  ovum,  they  practically  are  sterile. 

Endometritis,  the  most  common  of  intra-uterine  diseases,  bears 
a  very  important  relation  to  sterility.  It  not  only  interferes  with 
gestation,  but  the  dense,  glairy  discharge  it  produces  may,  by 
plugging  the  cervical  canal,  not  only  obstruct  the  entrance  of 
spermatozoa,  but  by  its  toxicity  destroy  or  inhibit  their  vitality. 
Catarrhal  states  of  the  Fallopian  tube  often  result  from  endometritis. 
The  mucus  it  produces  may  so  coat  the  ovule  in  its  downward 
passage  that  the  permatozoa  either  cannot  penetrate  it  or  else  they 
are  killed  by  its  toxic  properties. 

There  are  numerous  other  etiologic  conditions,  some  of  which 
are  symptomatically  associated  with  those  already  mentioned.  In 
408  cases  of  sterility  studied  by  Kammerer  dysmenorrhea  was  ob- 
served in  69 ;  menorrhagia  and  metrorrhagia  in  57,  scanty  menstru- 
ation in  41,  amenorrhea  in  2,  delayed  menstruation  in  8,  hysteria 
in  16,  nervous  headache  in  3,  intercostal  neuralgia  in  1.  Some  of 
these  derangements  probably  had  no  causal  relation  to  the  sterility, 
but  depended  on  the  same  conditions  as  the  latter. 

A  profuse  uterine  discharge,  of  whatever  kind,  may  wash  away 
the  ovule  before  or  after  impregnation.  Dysmenorrhea  undoubtedly 
is  a  frequent  cause  of  sterility.  In  the  membranous  form  sterility 
is  a  matter  of  course.  Dysmenorrhea  is  due  to  uterine  or  ovarian 
disease  or  to  some  obstruction  to  the  free  escape  of  the  menses.  It 
is  attended,  moreover,  by  spasmodic  uterine  contractions  that  may 
persist  as  a  matter  of  habit,  and  cause  the  expulsion  of  the  fecun- 
dated ovum.  The  same  conditions  that  produce  dysmenorrhea  also 
prevent  the  spermatozoa  from  entering  the  uterus  or  destroy  them 
after  they  have  entered. 

As  already  repeatedly  indicated  in  this  volume,  the  author 
believes  that  sterility  in  both  sexes  and  impotence  in  the  male  are 
largely  dependent  upon  aberrations  of  sex  hormone  secretion.  This 
is  im])ortant  in  the  consideration  of  treatment. 

This  will  be  again  referred  to  later. 

Following  Marion  Sims,  the  profession  in  general,  until  com- 
paratively recently,  held  that  sterility  in  the  female  was  almost 
entirely  due  to  some  cause  of  a  mechanic  nature  intrinsic  to  the 
individual  case,  such  as  is  induced  by  uterine  displacement.     Out  of 

—  166  — 


STKRIUTY    AND    IMPOTENCK    IX    THE    FEMALE 

this  fallacy  grew  two  methods  of  treatment,  viz.,  first,  the  Sims 
method  of  artificial  fertilization  —  which  never  became  popular,  but 
recently  has  been  revived  in  certain  quarters,  and,  second,  indiscrimi- 
nate surgical  tinkering  with  the  uterus  and  its  adnexa. 

Increasing  knowledge  of  the  effects  of  gonorrhea  have  greatly 
modified  our  views  of  sterility.  Especially  have  we  found  that 
morbidity  of  utero-vaginal  secretions  often  is  deadly  to  the  healthiest 
spermatozoon.  Acidity  and,  in  general,  toxicity  of  the  secretions 
of  the  female  sexual  tract  is  very  important  in  this  regard. 

In  an  excellent  presentation  of  his  method  of  diagnosis  of 
sterility,  Huhner  says : 

Treatment:  It  of  course  is  pre-supposed  that,  in  seeking  the 
causes  of  sterility,  the  possible  responsibility  of  the  husband  also 
has  been  investigated  thoroughly.  The  treatment  of  sterility  in  the 
female  demands:  1st.  The  surgical  correction  of  any  mechanical 
obstacles  to  fecundation.  2d.  Attention  to  such  constitutional  condi- 
tions as  apparently  are  contributory  to  the  sterility.  3d.  Such  local 
measures  as  may  be  demanded  for  the  cure  of  infections  and  the 
inflammatory  conditions  produced  by  infections.  4th.  The  removal 
or  neutralization  of  any  utero-vaginal  discharges  that  may  toxically 
impair  the  vitality  of  the  spermatozoa  or  mechanically  obstruct  their 
upward  passage.  5th.  Attention  to  the  time  —  relative  to  the 
menstrual  period  —  at  which  coitus  takes  place.  6th.  Correction 
of  any  untoward  conditions  that  might  impair  fertility.  7th.  Last, 
but  not  the  least,  the  questions  of:  (a)  Inherent  incapacity  for 
fecundation,  (b)  ^Marital  physical  incompatibility,  must  receive 
due  attention. 

Briefly,  obstntctions  to  intercourse  or  to  the  upward  passage 
of  the  spermatozoa  must  be  corrected.  Infections  —  notably 
gonorrhea  —  should  receive  careful  attention.  Here,  vaccines  —  and 
especially  auto-vaccines  — often  are  of  great  service. 

The  consideration  of  the  various  surgical  measures  of  correcting 
pathologic  conditions  of  the  female  genitalia  is  not  within  the 
province  of  this  volume.  So,  too,  with  the  treatment  of  gonorrhea 
and  its  results.  Hiihner's  suggestion  of  coitus  after  modification  of 
the  utero-vaginal  secretions  has  been  accomplished  by  an  alkaline 
douche  is  an  excellent  one,  and  has  the  merit  of  simplicity  and  safety. 

Limitation  of  intercourse  to  the  periods  immediately  preceding 
and    following   menstruation    often    overcomes    apparent     sterility. 

~  167  — 


IMPOTENCE  AND   STERILITY 

Uterine  stimulation  by  simple  dilation  of  the  cervix  sometimes  is 
effective. 

Intercourse  after  prolonged  marital  separation  not  infrequently 
results  in  impregnation. 

Where  sterility  apparently  is  due  to  inherent  incapacity  for 
fertilization,  or  to  sources  of  constitutional  depravity  and  exhaustion, 
the  sex  gland  hormone  may  be  of  value.  Corpus  luteum  substance 
logically  is  indicated  and  possibly  may  be  of  service,  especially  if 
combined  in  debilitated  conditions  with  tonics,  such  as  arsenic,  iron, 
quinine,  strychnia  and  phosphorus.  Where  anemia  is  evident, 
arsenic  and  iron  especially  are  indicated.  The  primary  condition 
which  lies  behind  the  debility  or  cachexia,  of  course  requires 
correction. 

In  conformity  with  his  view  that  sterility  revolves  largely 
around  aberrations  of  sex  hormone  supply,  the  author  believes  that, 
in  the  inherent  form  and  that  due  to  constitutional  debility  from 
non-malignant  disease,  or  due  to  causes  which  are  not  incurable 
per  se,  sex  gland  implantation  possibly  may  have  a  very  important 
field.  It  is  unnecessary  to  repeat  here  what  already  has  been  said 
of  the  relation  of  the  sex  hormone  to  fertility,  or  to  forestall  much 
that  will  be  exhaustively  considered  in  the  next  chapter. 

Physical  abuse  —  especially  physical  sexual  abuse  —  may  cause 
a  permanent  inhibition  of  sex  hormone  formation  in  women,  with 
resultant  permanent  frigidity  and  perhaps  sterility.  It  is  true  that 
such  women  may  conceive,  merely  because  there  still  may  be  enough 
hormone  and  its  quality  may  be  good  enough  to  maintain  the  nutri- 
tion of  the  ovule  and  make  conception  possible.  Here  would  be  a 
direct  indication  for  the  administration  of  sex  hormone,  in  the 
form  of  corpus  luteum  at  least,  if  not  by  implantation  of  sex  glands. 

After  conception,  the  psychic  and  circulatory  stimulus  afforded 
to  maternal  sex  hormone  supply,  by  the  ovule  itself,  may  be  sufficient 
to  insure  the  nutrition  of  the  fetus.  In  many  instances,  however, 
hormone  secretion  might  be  so  perverted  that  abortion  would  occur, 
or  a  defective  child  be  born. 

In  connection  with  what  seems  to  the  author  to  be  a  very  inter- 
esting field  for  speculation  as  to  the  importance  of  the  nutritive  role 
of  the  sex  hormone,  some  important  questions  suggest  themselves, 
viz. :     1.    Is  it  not  possible  that  the  sex  hormone  of  one  sex  may  by 

—  168  — 


STERILITY    AND    IMPOTENCE    IN    THE    FEMALE 

implantation  determine  the  sex  of  the  progeny,  if  successfully  ad- 
ministered before  conception  or,  perhaps,  even  later?  2.  Might  not 
fertility  be  induced  in  the  infertile  by  sex  gland  implantation? 
The  birth  of  an  heir  may  be  of  vital  importance.  3.  Alight  not  alien 
hormone,  administered  via  implantation  early  in  pregnancy,  possibly 
determine  the  development  and  birth  of  a  normal  instead  of  a  still- 
born, or  of  a  degenerate  child?  4.  Might  not  an  implantation  in 
one  or  both  parents,  by  the  action  of  the  alien  sex  hormone,  correct 
the  evils  of  consanguineous  marriage?  5.  ]\Iight  not  derangement 
of  a  hereditary  neuro-degenerate  type  be  corrected  during  early  life 
by  implantation  of  alien  sex  glands?  6.  Apropos  of  query  No.  5, 
might  not  the  influence  of  alien  sex  glands  be  even  greater  from  a 
racial  "cross,"  c.  ,([.,  of  Aryan  sex  glands  upon  Semitic  stock,  or 
of  Anglo-vSaxon  upon  the  Latin?  That  the  principle  might  be  too 
radically  applied  —  e.  g.,  by  cross  implantation  between  negro  and 
Caucasian  ^  is  suggested  by  the  known  deleterious  results  of  cross 
breeding  of  white  and  black,  and  yet  the  sex  hormone  of  the  very 
fertile  black,  might  add  just  the  right  element  to  the  blood  of  the 
relatively  infertile  white,  when  administered  by  implantation. 

The  interest  of  the  profession  in  the  method  of  artificial 
impregnation  first  suggested  by  Marion  Sims,  recently  has  been 
revived  in  certain  quarters.  Sims  was  almost  ostracized  by  the 
profession  for  suggesting  the  collection  of  the  semen  from  the 
vagina  of  the  wife  immediately  after  intercourse  and  its  injection 
into  the  uterus,  thus  overcoming  the  obstruction  which,  in  Sims' 
day,  was  supposed  to  underlie  most  cases  of  sterility.  Latterly  it 
has  been  suggested  that,  where  the  husband's  semen  is  infertile,  a 
fresh  condom  specimen  from  extra-domestic  sources  should  be 
used,  where  there  are  urgent  reasons  for  child  bearing.  Needless 
to  say  that  esthetic  objections  to  the  method  often  would  be  enter- 
tained to  this,  although  it  might  be  overruled  in  certain  instances. 
It  is  obvious  that  the  person  donating  the  semen  should  be  perfectly 
healthy.  A  series  of  Wassermann  examinations  and  tests  of  the 
prostato-urethral  secretions  for  gonococci  are  very  essential.  It  is 
important,  also,  that  the  vitality  of  the  spermatozoa  should  not  be 
impaired  when  the  specimen  is  delivered.  Keeping  the  condom  of 
semen  in  a  water  bath  at  blood  temperature  will  protect  the 
spermatozoa   from  inipairment   for  some  hours. 

—  169  — 


CHAPTER    IX. 
Spermatorrhea. 

Fkw  subjects  in  medical  literature  have  been  treated  in  so  con- 
fusing a  manner  as  has  spermatorrhea  by  the  few  authors  who  have 
deigned  to  give  it  attention.  The  special  treatises  upon  the  subject 
by  American  writers  have  been  limited  in  number,  and  authors  in 
general  have  well-nigh  ignored  it.  The  subject  formerly  was  so 
obnoxious,  because  of  the  treatises  of  quacks  and  impostors,  that 
reputable  physicians  showed  a  somewhat  excusable,  but  illogical, 
tendency  to  ignore  it  altogether.  It  is  a  remarkable  fact  that,  until 
recent  years,  nearly  all  of  our  knowledge  of  the  subject  had  been 
handed  down  from  the  classic,  yet  overdrawn,  treatise  of  Lallemand : 
a  work  that  has  been  extensively  quoted  —  both  the  original  and 
the  English  translation.  Excellent  monographs  have,  however,  been 
written  by  Milton,  Acton,  Howe,  Hammond,  and  Bartholow,  the 
latter  being  devoted  to  spermatorrhea  alone.  Alore  recently  have 
appeared  works  by  Taylor,  Ultzmann,  Vecki,  Cooper  and  others, 
and  numerous  articles  in  text  books  and  the  medical  press. 

It  is  unfortunate  that  the  reputable  general  practitioner  knows 
so  little  of  the  pathology  and  treatment  of  the  various  phases  of 
aberration  of  the  sexual  function  included  under  the  term  sperma- 
torrhea. As  a  rule,  the  physician  takes  little  interest  in  the  subject, 
probably  because  of  the  disrepute  into  which  it  has  been  brought  by 
impostors  and  quacks ;  and,  as  a  consequence,  cases  of  this  kind 
either  consult  the  charlatan  primarily  or  are  driven  to  him  by  the 
indifference  and  repugnance  exhibited  by  most  reputable  physicians. 
This  course  is  not  only  unjust  to  the  patient,  but  unworthy  of  the 
physician.  No  function  of  the  body  is  more  intimately  associated 
with  the  welfare  and  happiness  of  the  human  race  than  that  of  the 
•^exual  organs,  and  the  physician  is  no  more  justified  in  ignoring  its 

—  170  -.- 


SPERMATORRHEA 

disturbances  or  refusing  to  treat  patients  suffering  from  them  than 
in  the  case  of  aberrations  of  structure  and  function  of  the  stomach, 
hver,  or  kidneys.  It  is  not  at  all  remarkable  that  "spermatopathic" 
quacks  flourish  and  wax  fat,  when  the  reputable  physician  by  his 
neglect  of  a  plain  duty  to  humanity  actually  drives  patients  into 
their  toils.  It  is  unfortunately  true,  moreover,  that  a  course  of 
quackery  usually  produces  a  psychopathic  condition  that  makes  the 
patient  insusceptible  to  either  moral  persuasion  or  medical  treatment, 
should  he  finally  fall  into  the  hands  of  a  scientific  physician  who  is 
competent  and  willing  to  advise  him. 

The  definition  of  spermatorrhea  has  given  rise  to  considerable 
discussion.  The  majority  of  scientific  authorities  are  not  inclined 
to  accept  as  spermatorrhea  any  case  in  which  the  loss  of  semen  is 
attended  by  erection  and  ejaculation.  Spermatorrhea  as  a  steady 
flow  of  semen  probably  does  not  occur,  as  was  formerly  supposed. 
The  seminal  loss  occurs  only  at  intervals  and  under  special  condi- 
tions, largely  mechanic  in  character. 

It  is  evident  that  spermatorrhea  was  recognized  by  the  ancients. 
Thus,  under  the  name  of  tabes  dorsalis,  Hippocrates  describes  a 
condition  that  evidently  is  spermatorrhea,  as  follows : 

This  disease  proceeds  from  the  spinal  cord.  It  is  frequently  met  with 
among  newly-married  people  and  libertines.  There  is  no  fever,  the  appe- 
tite is  preserved,  but  the  body  falls  away.  If  you  interrogate  the  patients, 
they  will  tell  you  that  they  feel  as  if  ants  were  crawling  down  along  the 
spine.  In  making  water  or  going  to  stool  they  pass  semen.  If  they  have 
connection  the  congress  is  fruitless.  They  lose  semen  in  bed,  whether  they 
are  troubled  with  lascivious  dreams  or  not — they  lose  it  on  horseback  or  in 
walking.  To  epitomize,  they  find  their  breathing  difficult ;  they  fall  into  a 
state  of  feebleness,  and  suffer  from  weight  in  the  head  and  a  singing  in  the 
ears.  If,  in  this  condition,  they  become  attacked  with  a  strong  fever,  they 
die,  with  cold  extremities. 

Acton  defines  the  disease  as  follows : 

The  condition  or  ailment  which  we  characterize  as  spermatorrhea  is  a 
state  of  enervation  produced,  at  least  primarily,  by  the  loss  of  semen.  This 
term,  I  admit,  has  many  objections,  but  its  general  acceptance  would  render 
it  inconvenient  to  alter  it  or  to  employ  any  other. 

According  to  Bartholow,  the  term  spermatorrhea  should  be 
restricted  to  that  condition  in  which  involuntary  seminal  losses  occur 
with  sufficient  frequency  to  produce  a  definite  morbid  state. 

—  171  — 


IMPOTENCE  AND   STERILITY 

Many  surgeons  regard  spermatorrhea  as  a  loss  of  semen  inde- 
pendently of  intercourse  or  masturbation :  i.  e.,  involuntary  losses  of 
all  kinds.  This  interpretation  of  the  term  is  objectionable  because 
of  its  comprehensiveness.  It  necessarily  embraces  certain  conditions 
in  which  involuntary  emission  of  semen  occurs  as  a  perfectly 
physiologic  phenomenon.  Some  authorities  will  not  accept  as 
spermatorrhea  any  case  in  which  the  discharge  from  the  urethra 
does  not  contain  spermatozoa,  as  demonstrated  by  microscopic  ex- 
amination. This  is  too  sweeping,  for  in  severe  cases  the  formation 
of  the  seminal  elements  may  finally  cease,  the  other  ingredients  of 
the  seminal  secretion  being  normal  or  nearly  so.  According  to  the 
author's  views,  the  term  spermatorrhea  should  be  applied  to  all 
involuntary  seminal  discharges  that  occur  without  orgasm. 

Seminal  losses  with  orgasm  are  most  conveniently  styled 
pseudospermatorrhea.  The  frequency  of  involuntary  losses  is  no 
diagnostic  criterion,  for,  while  robust  individuals  might  not  be  in- 
jured by  two  or  three  discharges  weekly,  delicate  patients  might 
be  powerfully  affected  by  a  single  weekly  emission.  In  estimating 
the  importance  of  involuntary  emissions  due  consideration  should 
be  given  to  their  effect  upon  the  mind  of  the  patient.  For  example, 
a  patient  who  is  ignorant  of  sexual  physiology  and  has  read  quack 
literature  extensively  may  be  greatly  depressed  and  worried  by  an 
emission  occurring  once  in  three  or  four  weeks,  while  another  less 
impressionable  individual,  who  knows  something  of  sexual  phys- 
iology and  has  not  had  his  mind  poisoned  by  fallacious  treatises, 
will  bear  several  emissions  weekly  without  apparent  ill  effects.  The 
assertion  has  been  made  that  nocturnal  emissions  are  no  more  injuri- 
ous in  their  effects  upon  the  nervous  system  than  similarly  frequent 
acts  of  normal  intercourse.  The  author  does  not  believe  this  to  be 
true.  Whether  or  not  the  depression  resulting  in  many  patients 
from  an  occasional  emission  is  altogether  due  to  the  moral  im- 
pression produced  by  it  is  open  to  question,  but  certain  it  is  that 
intelligent  individuals  with  a  knowledge  of  sexual  physiology  claim 
that  such  emissions  are  much  more  enervating  than  normal  inter- 
course. They  confessedly  lack  the  physiologic  stimulation  and 
mental  satisfaction  of  normal  coitus.  The  lack  of  normal  sex 
hormone  production  in  the  absence  of  proper  psycho-sexual  stimulus 
may  be  a  factor  in  this. 

—  172  - 


SPERMATORRHEA 

Etiologv.  —  Lallemand's  theory  of  the  pathology  of  sperma- 
torrhea inipHes  the  existence  of  irritation  of  the  prostatic  urethra 
and  seminal  ducts  produced  by  various  influences.  He  admits  as 
causes  of  the  disease  gouty  and  rheumatic  conditions  of  the  sexual 
apparatus,  gonorrhea  and  stricture,  phimosis  and  accumulation  of 
smegma  preputii,  masturbation  and  sexual  excess,  the  excessive  use 
of  such  drugs  as  cantharides,  ergot  and  various  diuretics,  intemper- 
ance, excessive  drinking  of  coffee  and  tea,  constipation,  irritation 
of  the  rectum  from  ascarides,  hemorrhoids,  fistula,  prolapsus  ani, 
etc.  He  claimed  that  in  severe  cases  he  had  demonstrated  upon 
autopsy  inflammation  and  thickening,  with  sometimes  ulceration  of 
the  vesicuUe  seminales,  ejaculatory  ducts,  and  prostatic  urethra. 
Recent  investigations  in  the  patholog}^  of  the  seminal  vesicles  —  and 
especially  of  the  colliciihis  seminalis  —  vindicate  Lallemand  to  a 
certain  degree. 

The  author  regards  the  essential  condition  in  spermatorrhea  as 
hyperesthesia  and  exhaustion  —  "irritable  weakness"  —  of  the 
general  nervous  supply  of  the  genitalia,  the  special  areas  of  sexual 
sensibility  in  the  genitalia,  the  afferent  nerves  of  sexual  sensibility, 
the  genito-spinal  center,  and  the  psycho-sexual  centers  in  the  brain. 
Hyperesthesia  of  the  caput  gallinaginis  is  a  most  important  element, 
both  in  true  and  false  spermatorrhea.  There  certainly  is  exhaustion 
and  irritability  of  the  nervous  system,  probably  occurring  in  the 
following  order:  1.  Of  the  nerve-supply  of  the  area  of  special 
sexual  sensibility  on  the  floor  of  the  prostatic  urethra.  2.  Of  the 
afferent  nerves  of  sexual  sensibility.  3.  Of  the  transmitting  fibers 
of  the  spinal  cord.  4.  Of  the  receiving  centers  of  the  brain.  The 
final  result  is  a  greater  or  less  loss  of  general  nerve-tone ;  i.  e., 
neurasthenia.  The  author  does  not  wish  to  imply  that  these  effects 
are  not  more  or  less  simultaneous,  but  that  the  serious  results  are 
likely  to  be  manifested  in  the  order  named.  Inasmuch  as  sperma- 
torrhea in  the  majority  of  instances  is  the  result  of  sexual  excess 
or  masturbation,  and,  moreover,  the  effects  of  the  venereal  orgasm 
being  expended  upon  the  nervous  system,  it  is  rational  to  infer  that 
the  disease  when  fully  developed  essentially  is  a  neurosis.  Bartholow 
expresses  a  similar  view,  which  is  in  direct  opposition  to  Lallemand. 
According  to  Bartholow,  spermatorrhea  is  always  a  neurosis,  and 
any  structural  alterations  that  may  be  found  are  coincidental,  not 

—  173  — 


LMPOTENCE  AND   STERILITY 

causative.  He  asserts,  moreover,  that  Ivallemand's  cases  in  w^hich 
organic  changes  in  the  sexual  organs  were  claimed  as  the  essence  of 
the  disease,  were  selected  for  the  purpose  of  justifying  his  theory 
and  practice. 

Sir  Henry  Thompson  claims  that  sexual  indulgence  cannot  have 
the  effect  of  producing  prostatitis  —  considered  to  be  so  important 
in  the  etiology  of  spermatorrhea  by  Lallemand  —  unless  gonorrhea 
already  exists.    This  dictum,  however,  the  author  cannot  accept. 

Peyer  says : 

Spermatorrhea  in  itself  is  not  a  disease,  as  little  as  is  fluor  albus  in  the 
female  sex,  but  is  onlj^  a  symptom  of  various  pathologico-anatomic  conditions, 
affecting  either  locally  the  seminal  vesicles,  their  ducts,  their  muscles,  and 
surrounding  mucous  membrane,  or  else  resulting  from  general  disturbances 
of  the  body,  especially  in  the  nervous  system.  The  several  nervous  disorders 
that  accompany  spermatorrhea  are  mostl}'  not  its  consequences,  but  co-ordi- 
nate symptoms  of  a  pathologico-anatomic  condition :  the  original  cause  of 
this  loss  of  semen. 

Granted  that  spermatorrhea  is  symptomatic  in  many  cases,  it  is 
not  necessarily  symptomatic  of  the  existing  perceptible  organic  local 
conditions  of  the  sexual  organs.  These  conditions  may  exist  coinci- 
dentally,  often  secondarily,  and  sometimes  are  produced  by  the  same 
causes  as  are  responsible  for  the  spermatorrhea,  the  essential  condi- 
tion underlying  the  spermatorrhea  being  in  the  nervous  system.  It 
is  a  striking  fact  that  spermatorrhea  is  very  rare  among  the  host 
of  patients  who  consult  the  surgeon  for  prostatic  and  deep-urethral 
disease. 

The  most  important  local  condition  associated  with  sperma- 
torrhea and  pseudospermatorrhea  is  dilation  and  relaxation  of  the 
orifices  of  the  ejaculatory  ducts  as  a  consequence  of  frequent  over- 
distension. The  vesiculcc  seminales  in  the  first  instance  become  so 
hyperesthetic  that  they  are  intolerant  of  their  contents.  This  intoler- 
ance, in  combination  with  hyperesthesia  and  irritability  of  the  veru 
.nonianmn,  results  in  frequent  reflex  expulsion  of  the  semen.  The 
orifices  of  the  ejaculatory  ducts  finally  become  so  dilated  that  the 
semen  dribbles  away  at  will.  Such  cases,  however,  are  extremely 
rare.  It  is  not  the  loss  of  fluid  that  produces  debility  at  first,  but 
the  frequency  of  the  discharge  of  nervous  force  —  with  perturbation 
of  sex  hormone  production  —  which,  as  already  indicated  in  con- 
nection with  the  subject  of  masturbation,  is  quite  similar  to  that 

—  174  — 


SPERMATORRHEA 

produced  by  an  epileptic  attack.  As  a  consequence  of  frequentl)- 
recurring  orgasm  produced  in  sexual  intercourse  or  by  masturbation, 
the  organs  become  so  weak  that  the  jolting  produced  by  horseback- 
riding,  or  the  strain  incidental  to  gymnastic  exercise,  causes  an 
emission.  The  author  had  under  his  observation  a  case  of  a  young 
man  who  could  not  ride  a  trotting  horse  because  of  emissions  occur- 
ring in  rapid  succession.  So  hyperesthetic  are  the  sexual  centers 
in  many  instances  that  the  mere  thought  of  sexual  indulgence  pro- 
duces an  emission,  often  without  erection  or  sensation. 

Prolonged  sexual  excitement  without  gratification  is  one  of  the 
frequent  causes  of  the  simj)ler  forms  of  spermatorrhea.  Undue 
familiarity  with  women,  in  combination  with  the  fostering  influences 
of  immoral  literature  and  associations,  keeps  up  a  constant  irritation 
of  the  sexual  organs  that  increases  their  sensibility  and  stimulates 
the  secretion  of  semen.  If  the  patient  is  not  vicious  or  ignorant 
and  does  not  masturbate.  Nature  is  quite  likely  to  relieve  the  condi- 
tion of  turgescence  of  the  sexual  organs  by  an  emission  during 
sleep.  If  the  cause  be  not  removed,  the  seat  of  sexual  sensibility 
becomes  very  irritable,  the  organs  meanwhile  growing  weaker  until 
finally  involuntary  losses  become  extremely  frequent.  It  will  be 
observed  that  pseudospermatorrhea  may  merge  into  the  true  variety. 

Lallemand  divided  seminal  losses  into  nocturnal  and  diurnal, 
the  nocturnal  losses  being  frequent,  physiologic,  and  due  to  sexual 
excitement,  but  becoming  pathologic  after  a  time  in  some  instances 
because  of  their  abnormal  frequency.  Some  patients,  he  claimed, 
were  subject  to  both  diurnal  and  nocturnal  escape  of  semen.  Diurnal 
emissions,  according  to  this  authority,  are  much  less  frequent  than 
those  occurring  at  night,  althotigh  they  are  more  serious  and  more 
rebellious  to  treatment.  They  occur  mostly  without  erection  or 
ejaculation,  during  or  just  following  the  acts  of  defecation  and 
micturition.  The  results,  after  the  disease  is  well  established,  were 
described  by  Lallemand,  as  follows : 

The  penis  becomes  relaxed,  the  erection  feeble.  The  corpora  cavernosa 
either  atrophy  or  their  vessels  lose  tonicity ;  the  corpus  spongiosum  and  the 
glans  penis  also  shrink.  The  testes  undergo  a  certain  degree  of  atrophy;  the 
superficial  veins  of  the  penis  become  dilated  and  tortuous.  The  nervous 
system  very  often  manifests  sympathetic  disturbances  in  the  form  of  vertigo, 
pains  along  the  course  of  the  principal  nerves,  etc.  The  subjective  symptoms, 
after  a  variable  longer  or  shorter  period,  become  very  marked ;  there  are 
pains  in  the  lumbar  region,  aching  in  the  arms  and  testes ;  capricious  appetite 

—  175  — 


IMPOTENCE  AND   STERILITY 

and  feeble  digestion ;  the  bowels  become  deranged,  constipation  alternating 
with  diarrhea. 

The  evil  habit  of  masturbation,  if  continued,  produces  great 
irritation  of  the  procreative  organs  —  especially  of  the  seat  of 
sexual  sensibility  in  the  prostatic  urethra.  Sensations  originating  in 
the  seat  of  sexual  sensibility  are  transferred  to  the  psycho-sexual 
brain  centers,  producing  erotic  thoughts.  Conversely,  erotic  thoughts 
are  reflected  to  the  seat  of  sexual  sensibility  in  the  form  of  voluptu- 
ous sensation.  Under  such  conditions  neither  physical-sexual  nor 
mental-sexual  rest  is  possible,  day  or  night.  Erotic  dreams  result, 
with  losses  of  seminal  secretion.  This  may  merge  into  true  sperma- 
torrhea, the  morbid  condition  finally  becoming  so  pronounced  that 
with  little  or  no  provocation,  losses  occur  in  the  day-time.  In  severe 
cases  the  seminal  secretion  sometimes  escapes  with  the  urine. 

In  the  milder  cases  of  erotic  dreams  and  nocturnal  losses  the 
condition  is  absolutely  physiologic.  Such  losses  constitute  Nature's 
method  of  disposing  of  excessive  secretion.  In  subjects  who  previ- 
ously have  lived  a  regular  sexual  life  in  the  matrimonial  state,  sexual 
deprivation  produces  the  same  result. 

The  specious  advertisements  of  the  charlatan  concerning  noc- 
turnal losses  are  cunningly  devised  to  impress  the  layman  with  the 
belief  that  all  cases  are  alarming  and  lead  to  "lost  manhood."  The 
credulity  and  ignorance  of  the  public  in  such  matters  have  fattened 
generation  after  generation  of  those  human  wolves,  the  advertis- 
ing quacks. 

Etiology:  The  causes  of  erotic  dreams  and  nocturnal  losses  are 
of  two  classes,  viz. : 

1.  Those  which  produce  erotic  thoughts. 

2.  Those  which  produce  irritability  of  the  sexual  organs, 
especially  of  the  deep  urethra  and  inflammation  of  the  colliculus 
seminalis. 

The  first  class  comprises  all  environmental  influences,  both 
psychic  and  physical,  which  tend  to  produce  hyperemia  and  hyperes- 
thesia of  (a)  the  seat  of  sexual  sensibility  in  the  prostatic  urethra, 
(b)   hyperactivity  of  the  genito-spinal  and  cerebro-sexual  centers. 

The  second  class  comprises  masturbation,  sexual  excesses  and 
infections ;  in  brief,  all  conditions  which  directly  produce  hyperemia 
or  inflammation  of  the  generative  organs  or  of  the  lower  urinary 
tract.     Obviously,  gonorrhea  is  an  important  factor. 

—  176  — 


SPERMATORRHEA 

It  is  obvious  that  the  psychic  and  physical  causes  overlap  or 
intermingle,  in  varying  degree  in  all  cases ;  c.  g.,  psycho-sexual 
stimulation  gives  rise  to  stimulation  of  the  sexual  organ  centers, 
and  vice  versa. 

Spermatorrhea  sometimes  is  a  symptom  of  nervous  disease, 
particularly  of  the  spinal  cord.  Thus,  it  is  occasionally  seen  in 
locomotor  ataxia.  In  conditions  of  this  kind  spermatorrhea  is  a 
secondary  consideration  and  should  be  regarded  as  such  with  re- 
spect to  treatment.  In  the  majority  of  instances  the  disease  is 
associated  with  complete  or  partial  impotence.  The  milder  types 
of  pseudospermatorrhea  are  quite  likely  to  be  associated  with 
pseudo-impotence  because  of  the  effect  of  the  nocturnal  emissions 
upon  the  mind,  rather  than  upon  the  virility  of  the  patient  per  se. 

Numerous  local  diseases  of  the  urino-sexual  organs  have  been 
mistaken  for  si)ernmtorrhea,  affording  abundant  material  upon 
which  the  patient's  mental  distemper  is  fed  by  the  quacks. 

Besides  nocturnal  emissions,  the  organic  affections  and  func- 
tional perturbations  that  are  most  often  erroneously  termed  sperma- 
torrhea are :  chronic  urethral  catarrh,  stricture  with  accompanying 
gleet,  prostatorrhea,  premature  ejaculation  of  semen,  vesical  catarrh, 
and  phosphaturia.  Phosphaturia  and  prostatorrhea  have  been  a 
veritable  gold  mine  for  the  charlatan. 

Varieties  of  True  Spermatorrhea.  —  1.  Diurnal  emissions 
without  erections  or  sexual  stimulation  of  any  kind. 

2.  Frequent  nocturnal  emissions  without  sensation  or  power: 
/.  c,  escape  of  semen  with  neither  pleasurable  sensations,  dreams, 
nor  erections. 

3.  Escape  of  semen  on  slight  provocation  without  erection,  or, 
at  most,  with  imperfect  erection, 

These  varieties,  in  a  measure,  may  be  associated.  Usually 
where  there  are  diurnal  losses  there  also  are  unconscious  losses  at 
night.  All  varieties  usually  are  associated  with  complete  or  partial 
impotence.     Prostatorrhea  may  co-exist. 

Varieties  oe  Pseudospermatorrhea.  —  1.  Occasional  noctur- 
nal emissions,  with  orgasm,  usually  with  dreams,  and  almost  always 
accompanied  by  erections.  There  usually  are  no  injurious  effects 
except,  perhaps,  those  of  a  mental  character.  In  some  cases,  how- 
ever, the  various  disturbances  outlined  in  the  symptomatology  of 
true  and  false  spermatorrhea  result. 

—  177  — 


IMPOTENCE  AND   STERILITY 

2.     Premature   ejaculation  in  coitus,   associated   with   pseudo- 
impotence  (  "spermatospasmos"  ) . 


Microscopic  appearance  of  normal  human  semen,  a,  Sperma- 
tozoids.  b,  Columnar  epithelium,  c,  Bodies  inclosing  lecithin- 
granules,  d.  Squamous  epithelium  from  the  urethra,  d. 
Testicle-cells,  e,  Amyloid  corpuscles.  /,  Spermatic  crys- 
tals,   g,  Hyaline  globules. 


r  (a)   From  prostatic  hyperemia  and  hyper- 

3.  Prostatorrhea  J  secretion. 

\   (b)   From  follicular  prostatitis. 

4.  Hypersecretion  of  the  urethral  and  prostatic  glands  during 
erection. 

5.  The  appearance  of  spermatozoids  in  the  lu-ine  after  erec- 
tions, coitus,  etc. 

6.  Discharge  of  semen  during  a  very  difficult  stool. 

7.  Discharsfc  from  chronic  lu'ethral  catarrh. 


—  i: 


SPERMATORRHEA 


Predisposing 
causes 


TABULATED  ETIOLOGY  OF  SPERMATORRHEA  AND 
PSEUDOSPERMATORRHEA. 


f    (a)   Defective   will-power    and   unstable   nervous 
equilibrium. 

(b)  Effeminate  and  defective  physique. 

(c)  Hereditary  inordinate  sexual  desire. 
General    .;     (d)   Mental  influences  exciting  sexual  desire ;  c.i?., 

erotic  novels,  pictures,  and  stories. 
(c)    Evil  associations  and  example. 
(/)    Freedom  from  restraint  in  associating  with 

the  opposite  sex. 
(17)   Excesses  in  eating  and  drinking. 

f    (a)   Precocious  development  of  the  sexual  organs 
and  function. 
(6)   Maldevelopment   of   sexual    organs,   such  as 
hypospadias  and  phimosis.    Imperfectly  de- 
veloped and  weak  testes. 

(c)  Acquired  conditions  of  disease,  such  as  phi- 
Local        i  mosis,  stricture,  urethritis,  prostatic  conges- 
tion and  inflammation,  cystitis,  stone  in  the 
bladder,  coUiculitis,  seminal  vesiculitis,  ba- 
lanitis, herpes,  and  constipation. 

(d)  Refle.x   irritation    from   hemorrhoids,   ascari- 
des,  fistula,  etc. 

(^  [(e)   Varicocele. 


(c)    Cerebro-spinal  disease  and  injuries. 


f  (a)   Masturbation. 

j    (b)   Sexual  excesses, 
hxcitmg  causes -<    / , 

Lff/)    Infection   (gonorrhea,  etc.). 

Symptoms  of  Spermatorrhea  axd  Pskudospermatorriiea. — 
The  line  of  demarkation  between  true  and  false  spermatorrhea  is 
determined  by  the  occurrence  or  absence  of  erection  and  orgasm  at 
the  time  the  emissions  of  semen  occur.  Aside  from  this  difiference 
the  symptoms  of  the  true  and  false  varieties  are  the  same,  differing 
in  degree  only.  It  of  course  is  understood  that  an  exception  is 
made  of  those  rare  cases  in  which  seminal  losses  are  the  result  of 
cerebro-spinal  disease  —  as  sometimes  seen  in  locomotor  ataxia. 

Local  Symptoius.  —  A  sense  of  weight  and  dragging  in  the 
testes  and  spermatic  cords ;  sensitiveness  and  perhaps  neuralgia  of 
the  testes,  urethra,  and  cords ;  relative  smallness  and  softness  of  the 
testes,  pendulous  scrotum,  congestion  of  the  pampiniform  plexus, — 

—  179  — 


IMPOTENCE   AND   STERILITY 

often  amounting  to  varicocele,  —  dilation  of  the  superficial  veins 
of  the  penis  and  relative  diminution  in  size  of  the  organ,  the  veins 
of  which  are  distinctly  enlarged,  coldness  and  loss  of  sensibility  of 
the  penis,  and,  most  important  of  all,  the  escape  of  semen  at  stool  or 
with  the  urine,  or  as  a  result  of  erotic  dreams  or  sexual  excitement. 
On  examination  the  entire  urethra,  prostate,  and  especially  the  pros- 
tatic urethra,  almost  uniformly  are  very  sensitive.  Partial  or  com- 
plete impotence  is  usual.  It  is  to  be  remembered  that  none  of  the 
foregoing  symptoms  are  characteristic ;  neither  are  they  of  impor- 
tance, so  far  as  spermatorrhea  is  concerned,  unless  involuntary 
seminal  discharges  without  orgasm  co-exist.  The  semen  is  ab- 
normally constituted,  being  thin,  and  more  or  less  watery.  It  often 
is  scanty  in  amount.  The  spermatozoa  are  relatively  few  in  num- 
ber, inactive,  and  poorly  developed  (oligospermia).  In  extreme  cases 
spermatozoa  may  be  absent  —  azoospermia. 

General  Symptoms.  —  There  is  more  or  less  disturbance  of  the 
sympathetic  nervous  system,  as  evidenced  by  capricious  appetite, 
impaired  digestion,  constipation,  or  diarrhea.  Pain  in  the  back, 
headache,  and  neuralgias  in  various  situations,  gastralgia,  and  ab- 
dominal pain  are  not  unusual.  The  headache  usually  is  occipito- 
frontal, and  sometimes  associated  with  more  or  less  marked  vertigo 
or  a  sense  of  cerebral  fullness.  The  skin  usually  is  sallow  and  pale, 
or  muddy.  Acne  is  plentiful  in  young  subjects.  The  facial  ex- 
pression is  one  of  care  and  anxiety,  or  of  deep  melancholy.  The 
subject  is  morbidly  self-conscious  and  inclined  to  shun  companion- 
ship. Profound  mental  depression  with  failure  of  memory  and  loss 
of  the  power  of  concentration  usually  are  prominent  symptoms.  The 
patient  acquires  the  habit  of  introspection  and  becomes  extremely 
hypochondriac.  His  genius  for  the  invention  of  symptoms,  fostered 
as  it  usually  is  by  reading  quack  literature,  becomes  phenomenal. 
Insanity  perhaps  is  rare,  but  suicidal  mania  occasionally  is  seen. 
Thoughts  of  suicide  are  a  choice  intellectual  morsel  with  a  large 
proportion  of  these  patients,  but  the  real  suicidal  intent  is  generally 
lacking.  Many  such  patients  come  to  regard  thoughts  of  suicide 
as  a  mild  sort  of  dissipation  which,  perhaps,  makes  their  melancholy 
more  tolerable.  The  knowledge  that  there  is  a  final  way  out  of 
their  troubles  —  although  they  are  not  in  the  least  inclined  to  take 
advantage  of  it  —  is  in  the  highest  degree  comforting  to  some 
spermatorrheic  or  spermatophobiac  patients. 

—  180  — 


si'j-:rmat()rrhea 

The  circulation  ^enerall}'  is  feel)le  in  spermatorrhea.  Coldness 
of  the  feet  and  hands  often  is  coni])lained  of.  and.  the  ptilse  is  likely 
to  he  irritahle  and  either  ((uick  and  feehle  or  irregular.  Lithemia  is 
a  fretitient  concomitant  of  the  disease.  Phosphatnria  and  oxalnria 
verv  freciuently  are  met  with  in  spermatorrhea,  oxaltiria  heing  es- 
peciallv  frecjttent.  'J'he  lumlxir  ])ain  so  often  met  with  is  not  uncom- 
monly due  to  oxahu'ia,  rather  than  to  the  sexttal  derangement  per  sc. 

Many  spermatorrheics  complain  of  disturhed  or  failing  vision. 
Blurring  or  spots  hefore  the  eyes  —  iiiitsciv  z'oUfa)itcs  —  are  the 
most  fre({uent  sotirces  of  complaint. 

The  most  important  varieties  of  i)setidospermatorrhea.  so  far 
as  their  liahilit}'  to  he  mistaken  for  trtie  spermatorrhea  is  con- 
cerned, are  characterized  hy  the  escape  of  semen-like  fltiid  from  the 
urethra  (a)  at  stool  (b)  with  the  last  straining  eti'ort  of  micturition, 
or  (c)  during  or  after  sexual  excitement,  either  with  or  without 
erection.     ]^>artholow  remarks  tipon  this  |)oint  as  follows: 

After  every  erection  without  ejaculation  there  is  a  mucous  flow  from  the 
urethra.  A  mixture  of  this  with  the  semen  produces  the  so-called  water\- 
semen.  The  same  discharge  is  often  ohserved  after  urination  and  defecation. 
It  alarms  the  patient  because  he  l)elieves  that  it  is  seminal.  These  are  the 
cases  to  which  AI.  kallemand  applies  the  term  "diurnal  pollution."  If  a  proper 
examination  of  this  fluid  he  made,  it  will  be  found  not  to  contain  si)ermatozoa. 
It  is  a  thick,  transparent  albuminous  fluid,  alkaline  in  reaction.  The  presence 
of  spermatozoa  is  essential  to  prove  the  existence  of  semen.  Xo  other  test 
is  applicable  than  the  micrf)scopic.  It  cannot  be  denied  that  spermatozoa 
may  be  found  in  the  lU'ine  or  mucous  secretion  from  the  urethra,  if  a 
nocturnal  emission,  or  an  emission  produced  by  natural  or  utmatural  means, 
has  recently  occurred  ;  l)ut  these  fluids  should  be  examined,  when  this  source 
of  error  may  be  eliminated. 

'Jliis  accords  with  the  views  of  Flint,  who  long  ago  said: 

In  most  of  these  cases  the  fluid  is  either  the  liquor  prostaticus  or  a 
secretion  from  the  vesiculse  seminales.  The  microscope  affords  the  only  mode 
of  determining  that  the  fluid  is  seminal.  Were  this  mode  of  examination 
generally  adopted,  cases  of  spermatorrhea  would  be  extremely  rare. 

Ihassell.  in  one  of  the  early  editions  of  his  work  on  the  ttrine. 
says : 

Care  must  be  taken  not  to  confound  the  discharge  of  urethral  gleet 
with  seminal  fluirl ;  the  distinction  is  easy,  since  the  former  is  distinguished 
by  the  presence  of  infusoria.  i)y  the  presence  of  scaly  epithelium,  and  by  the 
escape's  being,  in  general,  continuous.  Sometimes  the  gleety  discharge  occurs 
only  after  sexual  excitement  and  lasts  but  for  a  short  time,  when,  of  course, 

—  181   — 


I.MPOTHNCE   AND    STERILITY 

its  character  is  more  likely  to  be  mistaken.  The  prostatic  fluid  also  might 
be  mistaken  for  semen  ;  in  this  the  spermatozoa  also  would  be  absent,  and, 
in  addition,  the  microscope  would  reveal  in  it  the  presence  of  the  prostatic 
cylinders,  and  perhaps,  also,  of  the  peculiar  lamellated  concretions  of  phos- 
phate of  lime,  which  are  found  in  the  prostate  in  such  numbers.  Like  the 
mucus  from  ordinary  gleet,  that  from  the  prostate  may  also  be  continuous, 
but  more  frequently  it  appears  only  after  violent  efforts  of  defecation,  when 


Spermuria.     Last   drop   of   urine  exi)elled   in   a  case  of   sperma- 
torrhea. 


a  small  quantity  of  matter  may  be  expressed,  forming  only  a  drop  or  two, 
of  a  thick,  stringy,  and  transparent  fluid,  which  api)ears  at  the  oriiice  of  the 
urethra. 

It  is  easy  to  mistake  the  discharge  of  chronic  urethral  cartarrh 
for  semen.  'I'his  mistake  does  not  often  occtn',  however,  for  the 
experienced  man  with  past  gonorrhea!  trotihles  ttstially  does  not 
attribnte  his  discliarge  to  any  l)ut  the  real  cattse.  :V  moment's  re- 
flection is  sufficient  to  show  that  there  is  al)tindant  room  for  nn'stakes 
in  the  microsco])ic  diagnosis  of  urethral  discharges.  'I'he  prostatic, 
nrethral,  and  Co\v])er's  glands  are  prodigal  in  secretion,  and  slight 
stinnili  or  meclianic  ])ressure  often  are  snfficient  to  catise  the  secre- 

—  182  — 


SPERMATORRHEA  -     : 

tioii  to  appear  at  the  meatus.  Bladder-mucus  or  muco-pus,  and 
phosphatic  deposit  in  the  urine,  also  are  sources  of  error.  It  must 
be  remembered,  however,  that  in  genuine  spermatorrhea  sexual 
excitement  and  mechanic  pressure  may  cause  true  seminal  discharge, 
which  may  at  once  appear  at  the  meatus,  or  pass  backward  to  appear 
later  in  the  urine.  W^henever  true  semen  appears  at  the  meatus 
without  orgasm,  the  author  believes  that  the  function  of  the  muscular 
urethra  temporarily  is  inhibited,  or  overcome  by  prostatic  pressure, 
or  else  orgasm  occurs,  but  is  too  feeble  to  be  perceptible  to  the 
patient's  weakened  sensorium. 

Symptomatic  spermatorrhea  in  central  nervous  disease  requires 
brief  special  consideration.  As  might  be  inferred  from  the  fact  that 
sexual  excesses  and  masturbation  bear  an  important  etiologic  rela- 
tion to  locomotor  ataxia,  spermatorrhea  is  associated  with  that  form 
of  nervous  disease  more  often  than  with  any  other.  In  passing,  the 
author  desires  to  express  the  opinion  that,  notwithstanding  the  fact 
that  sexual  abuses  often  are  a  very  important  factor  in  tabetic 
etiology,  it  is  very  doubtful  if  such  influences  alone  ever  cause  tabes. 
Primary  predisposition,  —  often  involving  heredity,  —  syphilis,  alco- 
holism, and  nervous  overstrain,  one  or  all,  are  likely  to  co-operate 
with  faulty  sexual  hygiene,  which  becomes,  therefore,  merely  a  con- 
tributory cause,  albeit  an  important  one.  The  author  believes,  with 
most  syphilographers.  that  tabes  primarily  always  is  due  to  syphilis — 
hereditary  or  acquired,  usually  the  latter. 

Sexual  phenomena  in  tabes  usually  develop  in  the  early  stage 
of  the  disease.  Meryon,  Trousseau,  Duchenne,  Topinard.  and,  later, 
Bartholow  are  a  few  of  the  prominent  writers  who  have  called  atten- 
tion to  these  symptoms.     Topinard  speaks  as  follows : 

Four  symptoms  present  themselves  :  spermatorrhea,  satyriasis,  anaphro- 
disia,  and  impotence.  The  first  occurs  among  the  most  remote  antecedents 
of  the  first  period  of  tabes,  throughout  which  it  continues.  The  nocturnal 
pollutions,  at  first  accompanied  by  erections  and  a  sensation  of  pleasure,  at 
last  become  passive.  After  the  spermatorrhea,  or  without  having  been 
preceded  by  it,  there  occur,  after  some  months  or  years,  progressive  diminu- 
tion of  desire,  difficulty  in  procuring  satisfaction,  and  at  last  absolute  im- 
potence. 

Topinard  mentions  a  case  of  ataxia  in  which  the  patient  for 
thirty  years  was  tortured  by  priapism  so  obstinate  as  to  yield  only 
to  large  and  increasing  doses  of  opium.  This  is  rare ;  sexual  atony 
is  the  rule. 

—  183  — 


IMPOTENCE  AND   STERILITY 

Among  other  neuropathic  disorders  in  which  spermatorrhea 
often  occurs  as  a  symptom  may  be  mentioned  neurasthenia  from 
various  causes ;  tumors  and  other  diseases  of  the  pons,  medulla,  and 
especially  of  the  cerebellum ;  inflammation,  tumors,  and  syphilis  of 
the  spinal  cord ;  epilepsy,  certain  phases  of  insanity,  and  diabetes 
mellitus. 

With  reference  to  the  diagnosis  and  relative  importance  of 
symptomatic  spermatorrhea,  Bartholow  says : 

In  all  cases  in  which  the  involuntary  loss  is  a  symptom  it  is  of  little 
consequence  from  the  therapeutic  point  of  view :  the  centric  lesion,  of  which 
it  is  a  sign,  is  the  point  of  importance  to  which  our  attention  should  be 
directed. 

That  the  spermatorrhea  is  a  symptom  merely  should  be  easily  deter- 
mined by  reference  to  the  accompanying  lesions.  There  will  be  present  evi- 
dences of  degenerative  changes  in  the  great  vessels,  in  the  fundus  oculi,  in 
the  organs  of  special  sense,  and  in  cerebro-spinal  centers.  As  a  rule,  sper- 
matorrhea as  a  substantive  affection  occurs  in  the  youtig,  in  men  at  the  most 
vigorous  period  of  life,  and  is  a  result  of  the  abuse  of  the  sexual  organs. 
On  the  other  hand,  spermatorrhea  as  a  symptom  appears  after  the  middle 
period  of  life,  during  the  decline  of  sexual  activity,  and  coincidently  with 
symptoms  indicating  lesions  of  the  cerebro-spinal  apparatus.  When  sperma- 
torrhea is  a  symptom,  the  important  centric  lesions  on  which  it  depends  soon 
manifest  themselves  by  other  and  more  characteristic  signs,  whereas  when 
spermatorrhea  is  a  disease  the  case  remains  in  very  much  the  same  state  for 
months  or  even  years.  Attention  to  these  points  hardly  can  fail  to  conduct 
the  examination  to  a  correct  conclusion. 

Because  of  its  relative  frequency,  pseudospermatorrhea,  while 
really  of  slight  pathologic  importance,  is  of  greater  clinical  moment 
than  the  genuine  form.  The  psychic  effects  of  spermatophobia  are 
so  numerous  and  varied,  and  so  magnified  by  the  imagination  of  its 
victims,  that  the  ingenuity  and  breadth  of  mind  of  the  physician 
often  are  sorely  taxed  in  the  management  of  such  cases.  While 
inexcusable,  it  is,  in  a  way,  hardly  remarkable  that  most  physicians 
are  content  with  a  laissec  faire  policy  in  dealing  with  spermatopho- 
biacs.  Conscious  that  the  patient  is  suffering  with  ailments  which, 
from  an  organic  standpoint,  are  maladies  imaginaires,  the  medical 
man  feels  justified  in  "pooh-poohing"  his  patient's  tale  of  woe 
which,  baseless  though  it  is,  is  yet  sufficiently  unutterable  to  the 
suiTcrer.  The  lack  of  an  organic  foundation  renders  the  symptoms 
none  the  less  prominent.  Pseudo-impotency  is  often  regarded  as  a 
fitting  subject   for  jest  on  the  ])hysician's  ])art,  but,  to  the  patient, 

—  184    - 


SPERMATORRHEA 

the  absence  of  erection,  or  the  presence  of  other  conditions  that 
render  successful  copulation  impossible,  is  terribly  real.  Each  and 
every  symptom,  therefore,  merits  consideration  — -  as  a  beginning  of 
suggestive  therapy,  if  nothing  more. 

The  spermatophobiac  invariably  becomes  extremely  hypo- 
chondriac and  practices  introspection  with  a  zeal  that  is  worthy  of 
a  better  cause.  The  slightest  sensation  of  a  subjective  character, 
which,  by  persons  of  a  normal  psychic  condition,  would  either  be 
ignored  or  attributed  to  some  rational  cause,  is  attributed  by  the 
sufferer  from  pseudospermatorrhea  to  seminal  losses.  Should  he 
perchance  discover  in  addition  to  an  occasional  emission  a  little 
cloudiness  of  the  urine,  or  a  slight  discharge  at  the  meatus,  during 
sexual  excitement,  after  micturition  or  during  a  difficult  stool,  his 
worst  fears  are  confirmed  and  he  believes  himself  a  victim  of  the 
worst  imaginable  type  of  spermatorrhea.  Should  he  have  any  re- 
maining doubts  as  to  the  diagnosis  they  are  dispelled  by  the  first 
chance  bit  of  quack  literature  that  he  peruses.  And  peruse  quack 
literature  he  will,  as  the  only  possible  source  of  enlightenment  upon 
sexual  matters.  Reliable  information  —  indeed,  the  simplest  physio- 
logic truth  —  often  is  denied  him  because  of  the  hide-bound  condi- 
tion of  an  ultra-ethical  and,  if  the  truth  were  known,  often  essen- 
tially hypocritic  profession.  The  author  is  aware  that  the  foregoing 
statement  has  a  decidedly  radical  flavor,  but  he  has.  nevertheless,  no 
hesitancy  in  expressing  the  view  that  some  phases  of  so-called 
medical  ethics  are  positively  sickening. 

The  symptomatology  constructed  by  spermatophobiacs  is  best 
appreciated  by  perusal  of  their  correspondence.  It  is  as  historians 
of  their  own  cases  that  these  patients  especially  distinguish  them- 
selves. All  experienced  neurologists  and  urologists  will  at  once 
recognize  the  type  shown  in  the  following  letter  received  by  the 
author : 

My  Dear  Doctor: 

You  will  doubtless  be  surprised  to  receive  a  letter  from  me  so  soon 
after  the  consultation  of  yesterday;  but,  on  reflection,  I  fear  that  I  gave  you 
a  very  meager  account  of  a  case  which  seems  to  me  much  more  serious  than 
you  realize,  judging  from  the  advice  j'ou  gave  me  to  "stop  studying  my 
symptoms  and  cultivate  a  spirit  of  indifference  toward  my  numerous  sensa- 
tions."   I  therefore  take  the  liberty  of  writing  my  symptoms  more  in  detail : — 

The  state  of  my  mind  is,  perhaps,  more  important  than  anything  else. 
As  I  told  you,  I  dread  getting  among  people,  no  matter  how  congenial  they 

—    18.T    — 


IMPOTENCE  AND   STERILITY 

may  be ;  but  I  did  not  tell  you  the  chief  reason  for  my  aversion  to  society. 
I  am  sure  that  my  appearance  betrays  my  condition,  and  many  times  I  know 
from  the  queer  way  in  which  people  look  at  me  while  talking  with  each  other 
that  they  are  discussing  my  ailment.  Imagine  my  feelings,  if  you  can.  Of 
course,  my  confusion  settles  all  possible  doubt  in  their  minds  as  to  the 
correctness  of  their  conclusions.  I  am  positive,  also,  that  the  horrible  odor 
of  which  I  spoke  to  you  really  does  come  from  the  affected  parts,  and  is  so 
plain  that  he  who  runs  may  read.  At  the  times  when  I  detect  the  odor,  the 
parts  seem  bathed  in  a  cold,  clammy  sweat,  though  the  skin  does  not  feel  wet. 
I  have  frequent  spells  of  ringing  in  the  ears,  and  sometimes  snapping  sounds 
with  some  pain  that  must  be  in  my  ear-drums.  Just  before  meals  I  am  dizzy, 
and  this  cames  on  just  from  hearing  dinner  announced.  I  notice  that  the  spots 
before  my  eyes  come  only  in  daylight  and  are  plainer  on  cloudy  days.  I  am 
sure  my  hair  is  getting  very  thin  and  it  seems  very  oily  at  times,  and  at  such 
times  the  scalp  is  hot  and  tingling.  Almost  always,  after  meals,  there  is  a  full 
feeling  in  my  stomach  and  bowels,  and  my  breath  seems  like  the  odor  of 
tobacco,  though  I  do  not  use  it.  I  get  very  much  depressed  at  times  and  feel 
like  suicide.  I  did  not  tell  you  this,  but  it  is  a  fact.  If  I  did  not  hope  that 
medical  science  has  some  cure  for  my  terrible  disease  I  doubtless  would  make 
away  with  myself  ere  long.  I  wish  that  at  my  next  visit  to  you  you  would 
examine  mj'  rectum.  I  am.  sure  there  is  something  wrong  there,  for  just 
before  and  after  my  bowels  move  I  feel  a  peculiar  crawling  sensation  that 
starts  just  at  the  opening  of  the  bowel  and  passes  along  the  stride  into  the 
testicles.  I  notice,  too,  that  these  organs — the  testicles — are  sometimes  drawn 
up  tightly  and  at  other  times  hang  quite  low,  the  left  one  actually  dragging 
at  times.  I  have  frequent  palpitations,  as  I  told  you,  but  perhaps  I  did  not 
tell  you  that  at  such  times  there  is  a  strange  tickling  and  fluttering  feeling 
at  my  heart  which  has  a  tendency  to  cause  a  sense  of  suffocation.  I  think 
that  I  have  given  you  the  most  important  symptoms  that  have  occurred  to 
me  as  being  necessary  to  give  you  besides  those  I  told  you  of  yesterday,  but, 
if  you  do  not  mind,  I  will  bring  a  full  written  list  of  all  of  them  the  next 
time  I  come,  which  will  assist  you  a  great  deal  in  the  treatment  of  the  case. 

Very  truly  yours. 


This  patient  did  indeed  present  a  complete  list  of  his  symptoms. 
It  covered  eight  pages  of  foolscap. 

TrivATment.  —  General  Considerations.  —  In  considering  the 
therapeutics  of  spermatorrhea  a  knowledge  of  the  relations  of  the 
involuntary  seminal  discharges  to  various  organic  and  functional  dis- 
turbances of  the  sexual  organs  or  nervous  system  —  or  both  —  is  of 
paramount  importance.  A  knowledge  of  the  pathologic  conditions 
underlying  seminal  losses  is  especially  valuable  in  assigning  to  sper- 
matorrhea its  proper  role  —  that  of  a  symptom.  Understanding  the 
symptomatic  character  of  involuntary  seminal  losses,  the  physician 

—  186  — 


TREATMENT    OF    SPERMATORRHEA 

is  not  likely  to  overrate  the  importance  of  certain  very  common  cases 
in  which  the  involuntary  discharges  constitute  but  little,  if  any,  de- 
parture from  the  strictly  physiologic.  If,  however,  he  labors  under 
the  erroneous  impression  that  the  disease-entity  consists  merely  in 
involuntary  discharges  of  semen,  he  is  likely  to  be  unnecessarily 
alarmed,  and,  what  is  worse,  he  is  likely  to  seriously  alarm  his 
patient.  In  true  spermatorrhea  it  is  to  be  remembered  that,  while  the 
disease  essentially  is  a  neurosis  — -  according  to  the  author's  view  — 
there  often  are  associated  with  the  neurosis  pathologic  conditions  of 
the  genito-urinary  system  that  demand  attention.  These  pathologic 
changes  may  have  arisen  coincidently  wnth  the  neurosis  —  being 
produced  by  the  same  causes  — -  or  they  may  either  precede  or  follow 
the  neurosis  —  being  due  to  causes  absolutely  independent  of  those 
producing  the  latter.  No  matter  what  relation  pathologic  changes 
in  the  genito-urinary  system  may  bear  to  spermatorrhea,  no  form  of 
treatment  is  likely  to  be  successful  that  does  not  aim  not  only  at  the 
correction  of  the  essential  neuropathic  condition,  but  also  at  the 
removal  of  co-existing  local  derangements.  Thus,  while,  in  the 
author's  opinion,  deep-seated  gonorrheal  infection  does  not  often 
cause  true  spermatorrhea,  it  may  co-exist  with,  and  constitute  a  very 
important  and  obstinate  factor  in  the  perpetuation  of  that  disease. 
An  intelligent  therapy  of  spermatorrhea  necessarily  must  compre- 
hend proper  treatment  for  the  conditions  produced  by  the  deep  in- 
fection, w^hatever  such  conditions  may  be. 

The  majority  of  cases  of  pseudospermatorrhea  are  due  to  condi- 
tions that  essentially,  if  not  absolutely,  are  physiologic.  This  has 
come  to  be  generally  accepted  by  reputable  physicians.  Unfortu- 
nately, however,  it  too  often  has  been  taken  for  granted  that  the 
patient  is  quite  as  well  balanced  mentally,  or  should  be  quite  as  well 
balanced  mentally,  and  should  be  quite  as  well  versed  in  the  princi- 
ples of  physiology,  as  his  medical  adviser.  When  a  youth,  perhaps 
barely  past  puberty,  immature  of  mental  development,  and  unstable 
of  nervous  system  —  to  say  nothing  of  the  melancholy  and  hypo- 
chondriasis produced  by  ungratified  sexual  desire  and  brooding  over 
an  imaginary  spermatorrhea  —  presents  himself  to  the  average  repu- 
table practioner,  he  is  either  laughed  at  for  his  ignorance  or  informed 
that  his  case  is  not  worthy  of  serious  consideration.  He  rarely  is 
convinced,  however,  that  his  case  is  deserving  of  ridicule,  still  less 

—  187  — 


IMPOTENCE   AND    STERILITY 

that  his  symptoms  are  "trifles  Hght  as  air."  On  the  contrary,  he 
becomes  convinced  that  his  case  is  either  more  serious  or  offensive 
than  his  physician  cares  to  undertake,  or  else  that  the  derision 
aroused  by  his  tale  of  woe  is  merely  a  subterfuge  to  conceal  medical 
ignorance.  Should  he  chance  to  consult  with  a  lay  friend,  more 
experienced  than  himself,  he  is  informed  that,  from  esthetic  motives, 
ordinary  physicians  object  to  treating,  or  even  studying,  such  im- 
portant and  serious  cases  as  his  own.  The  quack,  that  court  of  last 
resort  for  the  ignorant  and  incurable,  is  suggested  and  finally 
appealed  to. 

The  author  has  no  hesitancy  in  asserting  that  the  reputable  pro- 
fession itself  is  largely  responsible  for  the  opulence  and  indisputable 
power  of  the  quack.  Would  it  not  be  better  to  employ  the  same 
psychic  instability  that  is  utilized  by  the  quack  for  the  purpose  of 
alarming  the  patient  and  preying  upon  his  fears,  in  an  honest  en- 
deavor to  correct  his  psychopathic  state?  Therapeutic  suggestion, 
honestly  —  which  means  scientifically  —  used  will  relieve  most  cases 
of  pseudospermatorrhea,  both  psychically  and  physically,  and  keep 
them  out  of  the  hands  of  the  vultures  that  find  in  such  patients  their 
most  lucrative  victims.  The  patient  should  be  given  to  understand 
primarily  that,  while  his  case  demands  attention,  it  is  by  no  means 
so  serious  as  he  supposes  and  readily  will  yield  to  treatment.  He 
should  be  instructed  in  sexual  physiology,  but  not  expected  to  become 
an  adept  in  one  lesson.  Such  organic  or  functional  disturbances  as 
may  have  a  bearing  upon  his  symptoms  demand  careful  attention. 
Oftentimes  regulation  of  the  diet,  attention  to  the  bowels,  and  the 
passage  of  the  cold  sound  a  few  times  will  lessen  the  frequency 
of  emissions  which  the  practitioner  pronounces  off-hand,  physiologic. 
If,  in  the  meantime,  the  patient's  confidence  has  been  gained  and 
proper  psychic  control  attained,  the  result  is  likely  to  be  all  that 
could  be  desired.  There  are  very  few  spermatophobiacs  who  do  not 
demand  careful  attention,  for,  no  matter  how  trivial  the  sexual  de- 
rangement per  se,  the  patient's  psychic  state  is  such  as  to  make  his 
ailments  terribly  real  to  him.  The  author  takes  this  opportunity  of 
saying  that  in  his  opinion  the  neglect  of  the  profession  to  do  its 
full  duty  in  such  cases  is  responsible  for  much  suffering  —  both 
mental  and  physical.  It  is,  of  course,  understood  that  there  are 
occasional  cases  in  which  a  perfectly  healthy  subject  consults  the 

—  188  — 


TREATMENT   OF   SPERMATORRHEA 

physician  regarding  infrequent  emissions  the  significance  of  which 
the  patient  does  not  understand  and  whom  it  is  perfectly  safe  to  dis- 
miss with  a  few  words  of  instruction  in  sexual  physiolog>'.  It  is 
to  be  remembered,  however,  that  the  practitioner  is  not  often  con- 
sulted until  the  patient  has  developed  a  psychopathic  state  that 
demands  the  most  judicious  management. 

Prophylaxis.  •^-  Subservience  to  the  rules  of  sexual  hygiene  is 
preventive  of  both  pseudospermatorrhea  and  real  spermatorrhea, 
save  in  exceptional  instances  where  the  seminal  losses  are  symptom- 
atic of,  or  secondary  to,  debilitating  general  diseases  or  lesions  of 
the  nervous  system.  Even  in  the  case  of  locomotor  ataxia,  however, 
it  is  to  be  remarked  that  proper  sexual  habits  may  be  prophylactic, 
for  it  is  probable  that  sexual  excesses  bear  a  very  important  etiologic 
relation  to  that  disease.  The  various  features  of  genito-urinary 
and  sexual  hygiene  have  received  special  attention  in  the  chapters 
upon  impotence,  sterility,  and  masturbation.  The  cure  of  local 
organic  disturbances  of  the  sexual  organs  obviously  is  prophylactic 
of  spermatorrhea. 

Special  Treatment.  —  In  considering  the  treatment  of  pseudo- 
spermatorrhea it  is  well  to  remember  that  in  the  form  characterized 
by  more  or  less  frequent  involuntary  emissions  the  frequency  of  their 
occurrence  is  not  the  sole  criterion  of  their  importance.  The  im- 
portant point  is  the  degree  of  tolerance  of  the  emissions.  Just  as 
some  individuals  may  copulate  very  frequently  without  apparent 
harm,  certain  plethoric  subjects  may  apparently  tolerate  involuntary 
emissions  that  would  produce  most  disastrous  results  in  feebler 
subjects.  It  is  to  be  remarked,  however,  that  frequent  emissions  in 
themselves  are  usually  a  sign  of  disturbed  innervation  both  of  the 
sexual  organs  and  general  nervous  system,  or  of  some  local  source 
of  reflex  irritation.  Before  deciding  the  question  of  the  necessity 
of  treatment,  even  in  apparently  slight  cases,  it  is  wise  to  ascertain 
the  condition  of  the  sexual  organs.  The  emissions  may  be  a  symp- 
tom of  local  disturbance  of  a  congestive  or  inflammatory  character 
that  later  on  may  cause  serious  trouble,  but  which  may  be  readily 
relieved  by  proper  early  attention. 

By  far  the  most  important  measure  of  general  treatment  in  the 
class  of  subjects  seeking  advice  in  pseudospermatorrhea  is  physical 
training.     With  careful  development  of  the  muscular  system  will 

—  189  — 


niPOTENCP:  AND   STERILITY 

come  improvement  in  nervous  tone,  both  general  and  local.  Exercise 
should,  so  far  as  possible,  be  taken  in  the  open  air,  although  field- 
sports  should  be  aided  by  proper  gymnastic  training  to  secure  general 
and  symmetric  muscular  development.  Exercises  involving  pressure 
or  strain  upon  the  perineum  should  be  avoided,  as  a  rule.  Climbing, 
bicycling,  and  horseback-riding  are  especially  pernicious.  The  cold 
bath  or  cold  shower  —  very  cautiously  used  at  first  —  constitutes  an 
auxiliary  measure  of  great  value.  The  baths  should  not  be  pro- 
longed —  stimulation,  not  sedation  or  refrigeration,  is  desired  —  and 
should  be  followed  by  brisk  toweling,  or  rubbing,  either  with  the 
hands  of  an  attendant  or  by  means  of  a  flesh-brush  wielded  by  the 
patient  himself.  The  functions  of  the  kidney  and  bowel,  and 
especially  of  the  stomach,  demand  attention  in  all  cases  of  sexual 
disturbance.  Constipation  and  excesses  or  indiscretions  in  eating 
and  drinking  are  particularly  to  be  avoided.  Sexual  rest  —  both 
psychic  and  physical  — •  is  indispensable,  save  in  certain  cases  where 
matrimony  is  advisable,  either  primarily,  or  after  a  suitable  course 
of  treatment. 

It  is  not,  as  a  rule,  difficult  to  elicit  a  history  of  the  usual  cause 
of  spermatorrhea  —  masturbation  —  in  most  cases.  The  patient's 
frankness,  however,  often  has  a  limit.  He  alludes  to  the  habit  of 
masturbation  in  the  past  tense,  and  forgets  to  inform  the  physician 
that  he  has  not  yet  discontinued  the  practice.  If  the  inquiry  be 
pressed  closely,  he  usually  lies  outright.  It  has  been  the  author's 
experience,  however,  that  a  large  proportion  of  such  patients  event- 
ually can  be  induced  to  betray  themselves.  A  popular  method  of 
deceiving  the  physician  is  to  inform  him  that  masturbation  is  per- 
formed unconsciously  during  sleep.  This  is  a  possible,  but  un- 
questionably rare,  occurrence. 

A  very  valuable  method  of  diminishing  the  frequency  of  seminal 
emissions  is  sleeping  upon  a  hard  and  uncomfortable  bed.  Patients 
occasionally  discover  this  for  themselves.  Several  patients  of  the 
author's  have  derived  excellent  results  from  sleeping  upon  the  floor. 
A  hard  mattress  is  often  efifective.  Physical  discomfort  and  erotism 
are  somewhat  incompatible,  and  the  patient  whose  bones  and  muscles 
are  aching  from  a  vain  efi^ort  to  find  comfortable  and  luxurious  re- 
pose is  not  very  likely  to  be  disturbed  by  lascivious  dreams.  A  few 
weeks  of  this  practice  will  often  break  up  the  emission-habit.     Light 

—  190  — 


TREAT.MEXT    OF    SPERMATORRHEA 

and  relatively  cool  covering  is  advantageous.  In  a  general  way,  the 
tendency  to  nocturnal  emissions  is  directly  proportionate  to  the  lux- 
uriousness  and  warmth  of  the  bed. 

Certain  mechanic  appliances  have  been  used  to  break  up  the 
eiuission-habit.  The  most  effective  of  these  is  the  so-called  "sperma- 
torrhea-ring."  Although  originally  a  quack  device,  this  appliance 
often  is  successful.  It  consists  of  a  double  ring  adapted  to  the  cir- 
cumference of  the  penis  when  flaccid.  The  inner  or  elastic  ring 
holds  the  appliance  /';/  silu  after  it  has  been  slipped  upon  the  penis, 
while  the  outer  ring,  which  is  provided  with  moderately  sharp  me- 
tallic serrations,  inflicts  punishment  u|)on  the  member  whenever  it 
chances  to  become  erect.  The  ring  is  to  be  applied  at  night  and,  as 
a  rule,  if  an  erection  occvu's  the  patient  is  immediately  awakened — 
before  an  emission  can  take  place.  In  some  cases  erection  and  emis- 
sion occur  despite  the  appliance.  In  true  spermatorrhea  such  de- 
vices are  ineffective.  A  very  ingenious  device  is  a  similar  appliance 
connected  with  a  small  battery  placed  beneath  the  patient's  pillow. 
An  erection  completes  the  circuit  and  causes  a  small  alarm  bell  to 
ring,  awakening  the  patient  and  thus  forestalling  emission. 

Any  plan  that  will  serve  to  interrupt  the  emission-habit  is  likely 
to  be  successful.  It  has  been  noted  that  the  dorsal  decubitus  favors 
emissions,  theoretically  because  in  this  position  there  is  a  determina- 
tion of  blood  to  the  genito-spinal  center — relative  hyperemia — with 
consequent  heightening  of  reflex  sensibility. 

In  many  cases  the  patient  rarely,  if  ever,  has  an  emission  while 
lying  upon  his  side.  Under  such  circumstances  a  towel  tied  about 
the  body  in  such  a  manner  that  the  knot  rests  in  the  middle  of  the 
back,  often  serves  to  awaken  the  jmtient  or  make  him  so  vmcom- 
fortable  that  he  instinctively  and  unconsciously  avoids  the  dorsal 
decubitus.  In  some  cases  the  patient  has  emissions  only  while  lying 
upon  one  or  the  other  side.  Changing  to  the  opposite  side  is  often 
effectual  under  such  circumstances. 

In  cases  in  which  the  patient  fosters  emissions  by  handling  the 
genitals  during  sleep,  the  author  has  advised  the  patient  to  wear  a 
pair  of  ordinary  boxing-gloves  at  night.  This  simple  device  renders 
manual  manipulation  of  the  genitalia  quite  difficult. 

In  all  forms  of  spermatorrhea  complicated  by  chronic  conges- 
tion or  inflammation  of  the  prostate  or  —  as  is  frequently  the  case  — 
by  chronic  inflammation  of  the  vesicidae  scuiinalcs,  the  most  impor- 

—  191  — 


IMPOTENCE  AND   STERILITY 

tant  measure  of  treatment  is  massage,  performed  by  the  finger  of  the 
surgeon  via  the  rectum.  Instruments  have  been  devised  for  the  per- 
formance of  prostatic  and  vesicular  massage,  but  digital  massage  is 
the  only  safe,  intelligent  and  reliable  method.  Considerable  ex- 
perience is,  moreover,  necessary  to  the  proper  performance  of  the 
massage.  The  surgeon  with  short  stubby  fingers  often  merely 
wastes  his  time  in  attempting  to  perform  this  manipulation,  which 
is  in  itself  sufficiently  simple. 

Aphrodisiac  remedies,  like  those  of  an  opposite  character,  are 
used  far  too  recklessly  in  the  impotence  accompanying  sperma- 
torrhea. This  is  natural  enough,  considering  (1)  that  the  profes- 
sion in  general  overrates  the  potency  of  this  class  of  remedies,  and 
(2)  the  imperative  demand  of  the  patient  to  be  relieved  of  the 
sexual  incapacity  that  often  exists  in  pseudospermatorrhea  and  al- 
most always  in  true  spermatorrhea. 

In  the  author's  opinion  there  is  no  class  of  remedies  so  fallacious 
as  the  aphrodisiacs.  Erections  produced  to  meet  emergencies  by 
large  doses  of  aphrodisiac  drugs  are  pathologic,  and  inevitably  fol- 
lowed by  a  reactionary  depression  which  makes  the  patient's  sexual 
powers  more  unreliable  than  ever,  to  say  nothing  of  the  local  irri- 
tation produced  by  the  action  of  such  drugs  upon  the  genito-urinary 
mucosa.  In  moderate  doses,  however,  with  a  clear  understanding 
of  their  tonic  rather  than  their  aphrodisiac  properties,  there  are  a 
number  of  drugs  that  have  a  markedly  beneficial  eflfect  in  all  forms 
of  sexual  debility,  whether  characterized  by  spermatorrhea  or  not. 
Of  these  drugs,  phosphorus  is  the  most  reliable,  where  tolerated  by 
the  stomach.  It  is  best  given  in  the  pure  state  in  pill  form,  but  the 
dilute  phosphoric  acid,  the  phosphid  of  zinc,  and  the  hypophosphites 
are  quite  serviceable.  Nux  vomica  or  strychnia  and  its  preparations 
come  next  in  order,  and  may  be  advantageously  combined  with 
phosphorus.  Ergot  also  is  useful  as  tending  to  restore  muscular 
and  vascular  tone  to  the  genital  apparatus.  It  also  tends  to  the 
correction  of  nervous  hyperactivity  of  all  kinds,  and  is  too  seldom 
employed  with  this  object  in  view. 

The  most  overrated  remedy  for  diseases  uf  the  sexual  apparatus 
is  damiana.  That  this  drug  has  a  tonic  effect  in  spermatorrhea  and 
sexual  debility  in  general  is  true,  but  as  an  aphrodisiac  it  is  an  arrant 
fraud.     In  general,  it  is  inferior  to  strychnia.     The  drug  should  be 

—  192  — 


TREAT-MENT    OF   SPERMATORRHEA 

given  in  liberal  doses — 2  to  5  grains  of  its  solid  or  1  to  2  drams  of 
the  fluid  extract  three  or  four  times  daily. 

Cantharides  is  the  most  popular  of  all  remedies  of  the  aphro- 
disiac class.  It  has  been  the  basis  of  "love-philters"  from  time  im- 
memorial. Its  true  worth,  however,  can  be  summicd  up  in  very  few 
words.  As  an  aphrodisiac  it  is  not  only  unreliable,  but  such  results 
as  may  be  obtained  by  large  doses  are  pathologic,  and  therefore 
dangerous.  Given  in  rational  doses  as  a  tonic,  it  is  serviceable  to  a 
moderate  degree.  It  seemingly  has  a  general  tonic  effect,  and  in 
addition  a  somewhat  stimulating  action  upon  the  nerves  of  sexual 
sensibility  and  the  genito-spinal  center.  A  marked  degree  of  sexual 
stimulation  never  is  to  be  obtained  save  by  dangerously  large  doses. 
Nor  is  the  drug  always  reliable  in  producing  in  rational  doses  even 
a  mild  degree  of  stimulation  of  the  sexual  apparatus.  It  has  been 
claimed — and  it  must  be  confessed  wnth  some  reason — that  can- 
tharide  acts  locally  only  by  virtue  of  its  directly  irritant  action  upon 
the  genito-urinary  mucosa  z'ia  the  urine.  If  this  be  true,  any  stimu- 
lating effect  upon  the  genito-spinal  center  must  be  produced  reflexly. 
The  possibility  of  the  drug's  acting  by  virtue  of  an  irritant  effect 
upon  the  mucous  surfaces  of  the  genito-urinary  tract  should  impose 
additional  caution  in  its  administration  where  inflammatory  or  con- 
gestive conditions  of  the  sexual  organs  exist.  A  dose  of  more  than 
20  minims  of  the  tincture  rarely  should  be  exceeded,  although  by 
increasing  one  minim  daily,  as  suggested  in  the  preceding  chapter, 
this  dose  sometimes  may  be  exceeded. 

When  malformations  of  the  sexual  organs  exist  they  should 
be  corrected  by  surgical  measures  so  far  as  possible.  Phimosis  and 
meatal  stenosis  demand  attention  with  especial  frequency.  The 
various  other  conditions  already  enumerated  under  the  head  of 
predisposing  causes  should  be  sought  for,  and  if  found  should  re- 
ceive appropriate  surgical  treatment.  Disturbances  located  in  the 
rectum  and  anus  quite  frequently  are  overlooked.  These  conditions 
are  important  sources  of  exaggeration  of  the  genital  reflexes,  and 
require  most  careful  consideration. 

\^aricocele,  if  large,  always  demands  operation.  Even  in  the 
milder  forms  the  patient's  psychopathic  state  is  such  that  an  opera- 
tion often  is  not  only  justifiable,  but  positively  indicated. 

Such  conditions  as  prostatorrhea  from  prostatic  hyperemia  or 
follicular  prostatitis  have  received  attention  elsewhere  in  this  vol- 

—  193  — 


IMPOTENCE  AND   STERILITY 

ume.  Seminal  discharges  during  a  difficult  stool  should  be  ex- 
plained to  the  patient,  and  his  constipation  relieved.  In  many  such 
cases  the  prostate  is  the  seat  of  hyperemia  or  inflammation  de- 
manding especial  attention.  Hypersecretion  during  erection  and  the 
appearance  of  spermatozoids  in  the  urine  after  sexual  intercourse 
or  excitement  should  be  explained  to  the  patient  upon  a  physio- 
logic basis. 

Anaphrodisiac  measures  constitute  the  most  popular  routine 
treatment  for  spermatorrhea.  In  the  author's  opinion,  however, 
remedies  of  this  class  are  much  abused.  In  cases  of  what  may  be 
termed  the  sthenic  type,  characterized  by  a  greater  or  less  degree 
of  constitutional  vigor  associated  with  marked  sexual  irritability, 
anaphrodisiac  measures  are  a  distinct  advantage.  The  bromids  in 
free  doses,  gelsemium,  camphor  and  lupulin  are  types  of  this  class 
of  remedies.  In  many  cases  remedies  directed  to  the  alleviation 
of  irritation  of  the  mucous  membrane  are  distinctly  anaphrodisiac. 
Alkalies — the  salts  of  lithia  especially,  if  the  subject  be  gouty, — 
and  such  remedies  as  pichi,  buchu,  ustilago  maidis,  triticum  repens, 
and  the  balsams  are  of  service  under  such  circumstances. 

In  a  large  proportion  of  cases  of  pseudospermatorrhea,  and  in 
a  majority  of,  if  not  all,  cases  of  true  spermatorrhea,  a  tonic  rather 
than  a  sedative  line  of  therapy  is  demanded.  The  use  of  remedies 
of  the  aphrodisiac  class  as  tonics  already  has  been  dwelt  upon. 
Proper  exercise  and  bathing  for  improving  nervous  tone  have  also 
received  attention.  Quinin,  arsenic,  manganese,  and  iron — the  latter 
two  especially  if  anemia  exists — often  are  of  distinct  service.  The 
fluid  extract  of  salix  nigra  has  seemed  serviceable  as  a  sexual  tonic. 
It  is  well  to  remember  that  in  the  class  of  affections  under  con- 
sideration tonics  should  generally  be  combined  with  suitable  mild 
laxatives.  Constipation  is  nowhere  more  pernicious  in  its  effects 
than  in  diseases  involving  the  sexual  function.  One  of  the  best 
ferruginous  preparations  is  ferratin  in  tablet  form.  Pyrophosphate 
of  iron,  perhaps,  is  best  of  all.  One  of  the  most  valuable  tonics  at 
our  command  is  static  electricity.  The  general  tonic  effect  of  the 
static  current  is  not  so  generally  appreciated  by  the  profession  as 
it  deserves.  That  the  moral  effect  of  the  spark  is  valuable  in  pseudo- 
si)(jrmatorrhea  is  obvious.  The  high  frequency  current  is  very 
useful. 

—  194  — 


TR7{,\TMI'.XT    OF    SPER^fATORRHKA 

A  simple  yet  of  ten  effective  tonic  treatment  is  the  free  ingestion 
of  raw  eggs.  The  popular  notion  of  the  efficacy  of  eggs  as  an  aphro- 
disiac is,  of  course,  a  fallacy,  yet  their  effects  as  a  tonic  must  be 
admitted  and,  moreover,  they  seem  to  have  a  special  tonic  effect 
upon  the  sexual  apparatus.  In  several  cases  of  very  frequent  noc- 
turnal emissions  in  sickly,  delicate  lads,  the  author  has  obtained  ex- 
cellent results  from  the  free  use  of  raw  eggs.  \\'hether  the  beneficial 
ettcct  of  egg  is  to  a  certain  extent  due  to  the  small  amount  of  con- 
tained phosphorus  is  open  to  question ;  its  efficacy  may  well  be  attrib- 
uted simj:»ly  to  its  highly  nutritive  properties. 

I*sychotherapy  has  a  wide  and  im])ortant  field  of  usefulness  in 
the  various  forms  of  spermatorrhea.  Suggestion  necessarily  enters 
into  all  methods  of  treatment  to  a  certain  degree.  Cases  occur, 
however,  in  which  positive  efforts  in  this  special  direction  are  war- 
rantable. The  services  of  the  specialist  in  })sychotherapy  —  or  sug- 
gestion-therapy— sometimes  may  be  enlisted  to  good  advantage. 

Vibratory  massage  of  the  spine  and  genitalia  sometimes  appears 
to  be  of  service  in  disorders  of  the  sexual  function.  It  acts  both 
psychically  and  as  a  circulatory  stimulant. 

The  treatment  of  spermatorrhea  secondary  to  organic  cerebro- 
spinal disease  necessarily  resolves  itself  into  the  treatment  of  the 
primary  nervous  disorder.  In  many  cases,  however,  appropriate 
local  treatment  is  of  distinct  service  in  diminishing  what  is  obviously 
not  only  a  serious  drain  upon  the  patient's  vitality,  but  also  a  source 
of  most  profound  psychic  depression. 

Cold  sitz-baths  and  the  prolonged  local  application  of  cold 
water  to  the  genitalia — especially  the  testes — are  of  great  value  as  a 
sexual  sedative  primarily,  and  more  remotely  in  improving  the  tone 
of  the  sexual  organs.  Galvanism  applied  to  the  external  surface  of 
the  genitals  or,  in  selected  cases,  directly  to  the  prostate  via  the  rectal 
or  deep  urethral  electrode,  often  is  very  serviceable.  The  faradic 
current,  however,  often  acts  better  when  the  condition  is  largely 
psychopathic,  because  of  the  moral  effect  of  the  sound  of  the  rheo- 
tome.  Cold-water  enemata  often  are  of  service,  especially  where 
congestive  or  inflammatory  conditions  of  the  seminal  vesicles  exist. 
The  psychrophor  of  Winternitz — which  consists  essentially  of  a 
double-current  metallic  catheter — is  a  valuable  adjunct  to  the  treat- 
ment of  cases  characterized  by  urethro-prostatic  hyperesthesia.  The 
psychrophor  is  introduced  into  the  bladder  and  a  current  of  cold 

—  195  — 


IMPOTENCE  AND   STERILITY 

water — ice-water  if  necessary — made  to  pass  through  it  for  some 
minutes — the  time  varying  with  the  degree  of  tolerance.  This  is  to 
be  repeated  daily  or  every  second  day. 

In  general,  the  urethral  sound  is  the  most  useful  instrument 
for  the  local  treatment  of  all  forms  of  spermatorrhea.  If  introduced 
cold  and  allowed  to  remain  in  the  urethra  for  from  five  to  ten  min- 
utes it  combines  the  effects  of  mild  refrigeration  with  the  blunting 
of  nervous  sensibility  by  its  mechanic  action.  There  is  also  an  im- 
provement in  the  circulation  of  the  prostate  produced  by  the  pres- 
sure of  the  instrument  and  the  reactionary  hyperemia  incidental  to 
its  withdrawal.  The  milder  forms  of  pseudospermatorrhea  usually 
yield  readily  to  the  occasional  use  of  the  sound.  In  some  cases  the 
sound  is  painful,  though  the  psychrophor  is  well  tolerated.  Sound- 
ing usually  should  be  performed  twice  or  thrice  weekly. 

Direct  medication  of  the  prostatic  urethra — and  incidentally  of 
the  mouths  of  the  ejaculatory  ducts — is  a  very  popular  method  of 
treatment  of  spermatorrhea.  When  judiciously  and  aseptically  ap- 
plied, various  astringents  act  well  in  these  cases.  The  most  useful 
astringents  are  silver  nitrate,  copper  sulphate,  tannin,  thallin,  pro- 
targol  and  ichthyol.  These  may  be  used  in  the  form  of  suppository, 
ointment  or  solution.  The  most  useful  astringent  is  silver-nitrate 
solution  in  a  strength  of  2^  to  30  grains  to  the  ounce.  In  the 
author's  experience  a  relatively  mild  solution  in  considerable  quan- 
tity is  usually  best.  Where  strong  solutions  are  used,  only  a  few 
drops  should  be  injected.  If  the  instillations  are  followed  by  prosta- 
tic massage,  their  beneficial  effects  are  enhanced.  Applications  of 
strong  solutions  of  silver  nitrate  to  the  colliculus  sometimes  give 
wonderful  results.  Vasostomy  and  the  injection  of  silver  salts  into 
the  seminal  vesicles  is  sometimes  of  great  service  in  spermatorrhea. 

The  introduction  of  animal  extracts  into  medicine  was  seized 
upon  with  avidity  as  a  possible  solution  of  all  problems  in  the  therapy 
of  diseases  involving  the  sexual  function.  The  experiments  of 
Brown-Sequard  were  used  as  a  justification  of  all  sorts  of  quackery, 
"regular"  and  otherwise.  The  "fake"  solutions  of  spermin  and  its 
congeners,  fathered  by  a  noted  neurologic  specialist  of  this  country, 
will  be  remembered  in  this  connection.  In  view  of  the  nitroglycerin 
upon  w^iich  such  action  as  these  preparations  possessed  depended, 
it  is  not  surprising  that  their  false  pretensions  were  exposed.  Legiti- 
mate solutions  of  spermin  have  been  indorsed  as  of  limited  value. 

—  196  — 


TREATMENT   OF   SPERMATORRHEA 

The  dessicated  substance  of  the  sex  glands — testicle  and  ovary — 
of  late  have  been  very  popular  in  the  treatment  of  disorders  of  the 
sexual  system,  notably  impotence  in  the  male.  The  author's  ex- 
perience with  these  preparations  has  not  harmonized  with  that  re- 
ported by  a  number  of  other  surgeons  who  have  extolled  their 
action.  The  usefulness  of  the  orchic  preparation  appears  to  be 
limited.  Indeed,  so  far  as  the  author  is  able  to  judge,  its  action  in 
impotence  is  not  noticeable  unless  the  patient  knows  what  he  is  tak- 
ing. The  knowledge  that  he  is  taking  testicle  substance  sometimes 
appeals  very  strongly  to  the  patient's  imagination.  Its  action  in 
this  regard  is  like  that  of  the  lamb's  fries  and  Spanish  fries  diet  of 
the  man  about  town,  who  implicitly  believes  in  their  efficacy  as  a 
sexual  stimulant.  Inasmuch,  however,  as  there  is  a  more  or  less 
marked  psychic  element  in  all  cases  of  impotence,  the  preparation 
under  consideration  has  a  prominent  place  in  the  therapy  of  that 
disease. 

Corpus  luteiim  substance,  on  the  other  hand,  apparently  is  use- 
ful per  se  in  the  treatment  of  certain  conditions  in  the  female,  and 
apparently  is  a  much  more  potent  preparation  than  any  thus  far 
made  from  the  testicle  substance.  Pituitary  substance  and  adrenal 
cortex  substance  both  have  been  suggested  for  impotence.  The 
author  has  employed  these  preparations  in  a  limited  number  of 
cases,  but,  thus  far,  has  had  no  reason  to  be  enthusiastic  about  them. 
More  reliable  preparations  of  organic  products  eventually  may 
greatly  increase  their  usefulness.  Fresh,  vital  hormone-carrying  se- 
cretion can  be  successfully  employed  only  through  the  author's 
method  of  sex  gland  implantation,  which  will  be  discussed  in  the 
next  chapter. 

The  author  has  experimented  extensively  with  emulsions  of 
various  human  organs,  notably  of  the  brain,  testicle,  spleen,  pan- 
creas, liver  and  kidney,  has  shown  that  their  use  is  practicable,  and 
is  encouraged  to  believe  that  future  observations  may  show  that 
they  arc  of  distinct  value  in  various  conditions.  Emulsions  of  the 
brain  and  testicle  may  prove  of  special  value  in  certain  conditions, 
such  as  sexual  neurasthenia  and  impotence."' 

One  of  the  most  popular  methods  of  treatment  of  spermator- 


*Vlde  author's  paper,  "Experiments  with  Emulsions  of  Organs  from  the 
Dead  Human  Body,  and  Sex-glands  of  the  Lower  Animals." — American  Medi- 
cine. 1914. 

—  197  — 


IMPOTENCE  AND   STERILITY 

rhea  among  surgeons  of  a  past  generation  was  cauterization  of  the 
prostatic  urethra  with  pure  silver  nitrate  via  the  porte-caustique  of 
Lallemand,  an  instrument  which  the  great  Ricord  said  was  "re- 
sponsible for  more  eunuchs  than  all  the  harems  of  the  East."  Cau- 
terization of  the  prostatic  urethra  is  occasionally  justifiable,  but 
only  in  the  hands  of  the  expert,  and  never  by  any  method  other  than 
z'ici  the  endoscope  under  illumination  and  ocular  control.  The  caustic 
application  should  generally  be  limited  to  the  colliculus  seininalis, 
being-  made  with  a  view  of  lessening  hyperesthesia  and  curing  chronic 
inflammation  of  that  structure.  As  formerly  used,  complete  oblitera- 
tion of  the  mouths  of  the  ejaculatory  and  prostatic  ducts  was  a  fre- 
quent result  of  the  method.  Sterility  is  a  necessary  consequence  of 
such  rough  treatment. 

It  is  noteworthy  that,  while  he  carried  his  theory  and  practice 
to  extremes,  Lallemand  builded  wiser  than  he  knew,  as  is  shown  by 
the  stress  laid  by  the  modern  urologist  upon  morbid  conditions  of 
the  colliculus  in  the  consideration  of  the  pathology  and  treatment 
of  sexual  ailments. 

Marriage  often  is  advised  in  spermatorrhea  and  its  congeners. 
This  "prescription"  involves  very  serious  responsibility.  In  some 
cases  of  pseudospermatorrhea  the  physician  may  safely  advise  mat- 
rimony, but  he  should  use  great  care  in  determiining  the  patient's 
potency.  Even  psychic  impotence  may  be  a  bar  to  marriage.  In 
true  spermatorrhea  marriage  never  is  justifiable.  The  author  has 
commented  elsewhere  on  the  heinous  practice  of  prescribing  healthy 
and  presumably  innocent  women  in  the  treatment  of  masculine  de- 
generates who  cannot  be  other  than  wrecks  of  humanity.  Often- 
times the  game  is  not  worth  the  candle,  even  though  an  apparent 
success  be  obtained.  There  is  rarely  an  instance  in  which  the  woman 
])rescribed  does  not  get  the  worst  of  it.  Such  offerings  upon  the 
altar  of  Hymen — to  say  nothing  of  the  still  broader  question  of  in- 
fection— are  responsible  for  quite  a  proportion  of  the  sum-total  of 
human  misery,  lioth  physic  and  j^sychic.  Both  the  profession  and 
the  public  may  one  day  awake  to  a  sense  of  their  duties  in  this  mat- 
ter, and  the  time  may  come  when  proposals  of  marriage,  or,  at  least, 
n])plications  for  a  licen'^e  to  marry,  will  be  miorthodox  unless  accom- 
panied by  a  clean  bill  of  health  from  a  reputable  physician.  Half  the 
misery  of  the  human  race  comes  from  a  lack  of  supervision  at  the 
marriage-license  window.     ^Tarriage  is  too  easy,  divorce  too  diffi- 

—  198  — 


TRKAT-MKXT    OF    SPERMATORRHEA 

cult,  for  the  physical  and  moral  welfare  of  mankind.  Marriage 
should  at  least  be  as  difficult  to  enter  as  it  is  to  esca]De  from. 

There  are  certain  cases  of  spermatorrhea,  pseudospermator- 
rhea,  prostatorrhea  and  nocturnal  pollutions  in  which  the  resulting 
physical,  moral  and  psychic  degeneracy  demands  the  most  radical 
measures.  The  author  herewith  records  the  opinion  that  in  such 
cases  vasectomy  is  justifiable.  We  have  performed  it  in  many  in- 
stances, with  the  best  results,  and  shall  continue  to  perform  it  with 
perfect  confidence  in  its  harmony  with  the  highest  altruism  in  the 
relief  of  hvmian  stiiTering.  The  technique  of  the  operation  of  va- 
sectomy already  has  been  discussed. 

The  author  would  suggest  that,  before  performing  it,  its  results, 
so  far  as  sterility  is  concerned,  should  be  explained  by  the  surgeon 
in  the  presence  of  witnesses. 


—  199 


CHAPTER    X. 

Sexual  Neurasthenia. 

Sexual  neurasthenia  requires  special  consideration,  even  at  the 
cost  of  repetition  of  much  that  already  has  been  said.  It  implies 
ordinary  neurasthenia  with  a  sexual  element,  either  psychic  or  phys- 
ical in  character.  Organic  sexual  disturbances  hardly  can  exist  with- 
out a  strong  incidental  psychic  element.  A  purely  psychic  sexual 
element  in  sexual  neurasthenia  is  rare.  There  almost  always  is  some 
functional  derangement  of  the  sexual  apparatus,  behind  which  lies 
a  varying  degree  of  organic  disorder. 

The  author's  experience  leads  him  to  the  conclusion  that  neu- 
rasthenia in  the  male  is  associated  with  prostatic  hyperemia  and  hy- 
peresthesia, and  with  inflammation  of  the  prostatic  urethra,  more 
often  than  with  any  other  condition. 

Considering  the  abundant  sensory  and  sympathetic  nerve  sup- 
ply of  the  prostate  and  its  intimate  relation  to  the  sympathetic  sys- 
tem in  general,  the  frequency  with  which  nervous  symptoms  develop 
in  patients  suffering  from  prostatic  disease  is  not  remarkable.  Add 
to  the  purely  organic  factors  the  profound  psychic  impression  made 
upon  the  patient  by  the  knowledge  of  sexual  disability,  and  we  have 
a  very  satisfactory  explanation  of  the  frequency  of  "sexual  neuras- 
thenia." 

It  is  the  author's  belief  that  the  prostate  secretes  a  hormone  the 
perversion  of  which,  conjoined  with  the  absorption  of  infection 
toxins,  often  has  much  to  do  with  the  etiology  of  sexual  neuras- 
thenia. 

Disturbed  digestion,  irregular  bowel  action,  headache,  depres- 
sion, lassitude,  melancholy  and  brooding,  hypochondriasis  and  intro- 
spection, unstable  emotions  and  "hysteria" — for  there  is  a  condition 
in  the  male    analogous  to    hysteria    which  we  logically    might  call 

—  200  — 


SEXUAL    NEURASTHENIA 

"prostateria" — are  among  the  results  of  a  sensitive,  congested  pros- 
tate and  deep  urethra.* 

It  is  the  custom  of  the  reputable  profession  to  regard  the  sexual 
neurasthenics  who  are  the  prey  of  the  quacks,  as  sufiEerers  from 
purely  imaginative  ailments.  As  practically  all  of  these  subjects  have 
been  masturbators,  many  of  them  have  indulged  in  sexual  excesses, 
and  not  a  few  have  had  gonorrhea,  the  verdict  of  the  profession  is 
not  sound  as  regards  the  quack's  victim,  however  just  it  may  be  as 
to  the  quack  himself. 

Reputable  medical  men  are  wont  to  wave  the  sexual  neuras- 
thenic away  with  a  bluff  and  hearty,  "My  good  friend,  forget  it. 
There  is  nothing  the  matter  with  you."  The  patient  seeks  for  some 
one  who  will  sympathize  with  him,  and  goes  to  the  quack.  The 
quack  doesn't  diagnose  the  real  condition,  but,  to  the  patient's  cost, 
he  does  find  a  lot  of  things  that  do  not  exist,  and  all  because  the 
reputable  physician  flouted  as  imaginary,  conditions  which,  to  the 
patient's  sensitive  and  morbid  mood,  always  are  terribly  real.  The 
layman  who  feels,  however  mistakenly,  that  the  regular  profession 
is  both  ignorant  and  unsympathetic,  is  fine  material  for  the  charlatan. 

It  hardly  is  possible  for  one  to  indulge  in  either  masturbation  or 
sexual  excess  for  any  great  length  of  time  without  producing  dis- 
turbance of  prostatic  circulation  and  innervation.  The  physician  is 
likely  to  advise  such  patients  to  stop  their  evil  habits,  but  he  ignores 
the  sensitive  prostate  and  hyperesthetic  veru  ynontaninn,  which  con- 
tinually are  sending  sexual  stimuli  to  the  psycho-sexual  centers, 
where  they  are  at  once  transformed  into  erotic  ideas.  These  erotic 
pictures  of  the  imagination  reverse  the  nerve  current,  so  to  speak, 
and  increase  the  prostatic  irritation.  The  patient's  sexual  emotions 
are  used  as  a  shuttlecock  by  the  seat  of  sexual  sensibility  in  the 
prostate  on  the  one  hand,  and  the  psycho-sexual  centers  on  the 
other.  More  important  still  is  the  attendant  sex-hormone  perversion 
with  its  disastrous  effects  upon  all  the  organic  functions  and  upon 
cell  metabolism.  The  result  essentially  is  a  toxemia,  the  effects  of 
which,  especially  upon  the  nervous  system,  are  most  profound. 

Advising  the  patient  to  "keep  his  mind  off  the  sexual  organs," 
is  a  pseudo-Christian  science  prescription  which  usually  works  satis- 
factorily only  when  conjoined  with  the  instillation  of  a  little  nitrate 


•  The  author  dealt  In   extenso  with  the  subject  of  Sexual   Neurasthenia 
and   the  Prostate  in  the  X.   Y.   Medical  Record,  Feb.   3,   1912. 

—  201   — 


lAirOTENCE   AND    STERILITY 

of  silver  solution  into  the  prostatic  urethra,  supplemented  by  pros- 
tatic massage  and  the  cold  sound. 

Practically  every  masturbator  who  has  practiced  the  habit  for 
any  length  of  time  may  be  considered  a  neurasthenic  with  a  more 
or  less  tender  and  swollen  prostate.  Experience  shows  that  this 
condition  underlies  many  of  the  cases  of  nocturnal  emissions  with 
which  we  meet. 

The  analogy  between  the  prostate  and  seminal  vesicles  and  the 
uterus  and  tubes  is  nowhere  better  shown  than  by  pathologic  condi- 
tions of  these  organs.  The  infected  subinvoluted  uterus  and  tubes, 
with  the  surrounding  pelvic  infiltration,  producing  pressure  symp- 
toms and  neurasthenia,  have  their  counterpart  in  the  enlarged  in- 
fected prostate,  infected  seminal  vesicles,  and  periprostatic  infiltra- 
tion, producing  the  same  local  disturbances  and  general  nervous 
symptoms.  The  two  conditions  are  alike  also  in  the  matter  of  the 
stubbornness  and  lasting  quality  of  the  infection. 

The  management  of  sexual  neurasthenia,  while  largely  directed 
to  the  relief  of  local  conditions,  requires  even  more  care  and  judg- 
ment than  that  of  cases  of  neurasthenia  in  which  there  is  no  sexual 
element.  Regulation  of  sleep,  diet  and  work  always  is  in  order. 
Hydrotherapy,  tonics,  general  massage,  and  static  electricity,  or  the 
high  frequency  current,  all  have  their  uses,  in  conjunction  with  pros- 
tatic massage,  instillation  of  silver  and,  in  infected  cases,  irrigations. 
Urethral  dilations  and  endoscopic  applications  of  silver  should  sup- 
plement the  other  local  treatment. 

We  occasionally  meet  with  cases  in  which,  while  the  local  con- 
ditions improve  and  the  neurasthenia  is  more  or  less  benefited,  the 
patient  remains  unfit  for  the  active  duties  of  life  and  becomes  a  con- 
firmed hypochondriac.  For  cases  such  as  these,  complete  change  of 
scene  and  climate  is  required.  A  sea  voyage  sometimes  accomplishes 
wonders.  In  a  series  of  cases  of  the  author's  in  which  a  sea  voyage 
was  practicable,  the  results  were  all  that  could  be  desired.  In  one 
case  the  patient's  will  was  so  unstable  that  it  was  necessary  to  keep 
someone  with  him  constantly  until  the  steamer  started,  lest  he  should 
fail  in  his  determination  to  take  the  voyage.  He  was  so  emotional 
that,  when  his  frequent  fits  of  self-pity  came  over  him,  he  would  cry 
like  a  child.  This  meant  much  in  a  man  like  him,  for  he  was  an  ex- 
soldier  of  tried  mettle  and  courage.  He  first  went  to  the  Philippines, 
then  to  Japan.    He  returned  perfectly  well  in  five  or  six  months  and, 

—  202  — 


SEXUAL    NEURASTHENIA 

as  he  expressed  it,  "snapping  his  fingers  at  the  doctors."  This  case 
is  typic  of  a  number  in  the  author's  experience. 

vSexual  neurasthenia  associated  with  real  or  imaginary  sper- 
matorrhea, obstinate  jjrostatorrhea,  or  seminal  emissions  occurring 
frequently  and  resistant  to  treatment,  sometimes  is  very  difficult  of 
management.  In  such  cases  benefit  sometimes  is  obtained  from  tem- 
porary resection  of  the  z'asa  defcrentia.  Aside  from  the  moral  ef- 
fect— which  is  profound — the  relative  rest  secured  for  the  sexual 
apparatus,  and  the  lessened  activity  of  the  circulation  of  the  prostate 
are  extremely  beneficial.  As  the  attthor  has  shown  in  this  work  and 
elsewhere  (Journal  .V.  M.  A.,  July  21,  1906),  and  has  demonstrated 
in  liis  own  practice,  subsequent  anastomosis  is  perfectly  practicable, 
b}-  his  method  of  "cotipling"  the  vas. 

Cases  of  sexual  neurasthenia — with  or  without  prostatic  de- 
rangement— associated  with  impotence  are  the  most  trying  of  all. 
If  unrelieved,  these  cases  go  from  one  doctor  to  another,  and  finally 
land  in  the  arms  of  the  quacks.  ]\Iany  of  them  are  purely  psychic 
at  the  beginning,  but  a  few  recurrences  of  their  inability  to  copulate 
puts  a  large  proportion  of  them  into  the  permanent  class.  In  such 
cases  the  nomenclature  "psychic"  is  not  at  all  comforting  to  the 
patient,  which  is  not  astonishing,  inasmuch  as  potency  really  con- 
sists of  ability  to  secure  and  sustain  an  erection.  Our  nomenclature 
has  driven  a  host  of  patients  to  the  quacks.  The  cause  of  impotence 
may  be  psychic,  but  the  lack  of  erectile  power  per  se  is  a  purely  me- 
chanic and  obvious  proposition. 

In  many  cases  of  impotence  the  failure  of  erectile  power  ob- 
viously is  not  due  to  general  or  local  organic  conditions.  Once  the 
accident  of  failure  of  erection  has  occurred,  however,  the  patient's 
memory  of  the  first  time  is  sufficient  to  cause  another  and  another, 
until  failure  is  the  rule  of  his  sexual  life.  Even  the  removal  of 
determinable  organic  etiologic  conditions  is  likely  to  fail  to  cure 
sexual  neurasthenia,  once  the  habit  of  sexual  failure  has  been  es- 
tablished. 

Morbid  prostatic  conditions,  involving  especially  the  floor  of  the 
[jrostatic  urethra,  often  underlie  neurasthenia.  In  such  cases  pros- 
tatic massage,  silver  instillations,  or  endoscopic  applications  of  silver 
to  the  colliciilns  seiuhialis,  often  do  excellent  work. 

Xot  infrequently  all  measures  of  treatment  fail  completely.  If 
imjiotencc  exists  and  th.e  sexual  disability  is  unrelieved,  cure  of  the 

—  203  — 


IMPOTENCE   AND   STERILITY 

neurasthenia  is  impossible,  hence  any  measure  that  holds  out  even 
a  faint  hope  of  relief  should  be  adopted.  As  already  noted,  it  has 
been  the  author's  experience  that  a  very  respectable  proportion  of 
cases  of  sexual  neurasthenia  associated  with  impotence  are  rem- 
ediable by  resection  of  the  vena  dorsalis  penis.  As  to  how  far  the 
psychic  effect  of  the  operation  explains  its  benefits  one  need  not 
argue  in  the  face  of  mechanic  effects,  which  constitute  the  only 
means  of  physically  impressing  the  patient.  If  the  patient  notices 
an  increase  in  the  functional  activity  of  the  penis,  he  certainly  is 
justified  in  having  some  psychic  impressions  from  the  operation, 
and,  as  these  impressions  run  counter  to  those  which  have  been  a 
prominent  feature  of  his  sexual  disability,  the  operation  would  seem 
logical  enough.  Even  a  small  proportion  of  cures  would  justify  the 
operation,  and  as  the  proportion  really  is  encouraging,  the  procedure 
should  be  generally  employed  in  suitable  cases. 

In  otherwise  irremediable  cases  of  sexual  neurasthenia  the 
author  believes  that  treatment  with  sex-hormone  via  gland  implanta- 
tion is  a  rational  indication,  where  the  method  is  practicable.  The 
relation  of  the  sex-hormone  to  sexual  aberrations  of  the  organs  and 
functions,  and  to  neurasthenia,  already  has  been  touched  upon.  The 
subject  of  gland  implantation  will  be  fully  presented  in  the  next 
chapter. 


204  — 


CHAPTER    XI. 
Sex   Gland  Implantation. 

Successful  Auto-implantation  of  a  Testis  from  a  Subject 
Dead  Twenty-four  Hours  —  Other  Successful  Implanta- 
tions OF  Testes  and  Ovaries  from  Dead  Subjects  —  Ex- 
perimental Implantations  in  Various  Conditions,  and 
Cross  Implantations  of  Testes  and  Ovaries  Taken  from 
Dead  Subjects. 

Since  long  before  the  days  of  the  oophorectomy  craze — the 
darkest  blot  upon  the  history  of  the  surgery  of  the  last  quarter  of 
the  nineteenth  century — the  attention  of  the  profession  has  been  more 
or  less  insistently  directed  to  the  possible  relation  of  various  de- 
rangements of  the  sex  glands  to  certain  morbid  phenomena  of  a 
general  or  special  character,  notably  affecting  the  nervous  system. 
The  interest  aroused  finally  led  to  the  widespread  adoption  of  the 
Battey  operation,  which  once  was  so  disastrously  fashionable  as  a 
remedy  for  "neuroses"  in  women. 

The  period  at  which  the  author  himself  first  began  to  suspect 
that  in  many  cases  we  were  on  the  wrong  track,  is  fairly  well  fixed 
in  his  mind  by  two  personal  cases  that  occurred  during  the  then 
prevalent  epidemic  of  ovarian  mutilation  into  which  the  masters  of 
surgery  had  led  us.  These  cases  were  respectively  one  that  now 
probably  would  be  termed  dementia  prascox,  in  a  girl  of  twenty 
years,  and  another  of  "hystero-epilepsy"  in  a  girl  of  eighteen.  In 
the  former  the  author  set  about  removal  of  the  ovaries  to  relieve 
the  "reflex  irritation"  which,  according  to  the  then  fallacious  popu- 
lar theory,  presumptively  underlay  the  nerve  and  brain  symptoms, 
and  was  astonished  to  find  "atrophied"  —  or  more  probably,  un- 
developed —  ovaries  and  uterus.  In  the  other  case,  operation  was 
refused  and,  several  years  later,  the  author  had  the  opportunity  of 
making  an  autopsy,  the  young  woman  having  died  peacefully  without 

—  205  — 


IMPOTENCE  AND   STERILITY 

surgical  interference.  "Atrophied"  —  undeveloped  —  ovaries  and 
an  undersized  uterus  again  were  found.  Both  subjects  had  menstru- 
ated, although  tardily  and  irregularly  from  the  beginning,  but  finally 
menstruation  had  entirely  ceased. 

Even  at  that  early  period  of  the  author's  professional  career, 
these  cases  suggested  to  his  mind  the  possibility  that  an  aberration 
of  function  of  the  ovary,  rather  than  reflex  irritation  from  diseased 
ovarian  structure,  bore  an  etiologic  relation  to  some  of  the  manifold 
nervous  phenomena  in  women,  for  which  bushels  of  ovaries  were 
being  sacrificed.  In  the  light  of  recent  researches  in  the  field  of 
internal  secretions,  it  would  seem  that  possibly  the  profession 
builded  wiser  than  it  knew  in  attributing  to  ovarian  disease  a  host 
of  nervous  disorders  in  women. 

It  was  a  great  misfortune  that  we  then  had  no  knowledge  of 
the  internal  secretions,  and  no  blood  researches  to  show  us  that  the 
trouble  often  lay,  so  to  speak,  not  in  too  much  ovary,  but  in  what 
was,  in  efi^ect,  too  little,  the  internal  sex  gland  secretion  being  either 
insufficient  in  quantity  or  perverted  in  quality,  from  disease  or 
congenital  structural  defect. 

It  is  remarkable  that  the  nervous  and  other  phenomena  follow- 
ing castration  in  females  who  previously  were  normal  in  respect  to 
the  nervous  system,  did  not  make  matters  clearer  to  the  profession, 
but  possibly  our  attention  was  distracted  and  our  reasoning  powers 
were  inhibited  by  the  grave  discussions  with  which  we  were  regaled 
on  the  wisdom  of  "leaving  the  ovarian  nerves  intact"  when  we 
removed  the  ovaries.  Even  this  point  in  technic  was  regarded  as 
important  chiefly  because  of  the  consideration  of  the  influence  of 
the  ovarian  tissue  and  the  ovarian  nerve  upon  menstruation,  this 
function  being  regarded  as  the  main  factor  in  the  preservation  of  a 
normal  nervous  system  after  extensive  pelvic  mutilations. 

Since  the  inception  of  the  pelvic  mutilation  fad,  the  profession 
has  had  the  opportunity  of  observing  the  nervous  efifects  of  the 
Ramm-White  operation  of  castration  for  enlarged  prostate — now 
reposing  so  peacefully  in  the  surgical  dead  lumber  room  by  the  side 
of  the  long  defunct  epidemic  oi'jphorcctom\'  mania,  the  ghost  of 
which,  unhappily,  still  perverts  the  minds  of  a  few  of  the  surgically 
obscure  anrl,  what  is  worse,  inspires  the  malpractice  of  certain 
commercially   depraved   members   of  the  j^irofession. 

~-  206  -- 


SEX    CLAXD   IMPLANTATION 

It  is  noteworthy  that  Brown-Sequard's  self  experimentation 
with  the  extract  of  the  testes  of  lambs  really  signified  more  than 
either  he  himself  or  the  profession  comprehended.  Had  we  grasped 
the  great  principle  involved,  the  much  ridiculed  "elixir  of  life"  prob- 
ably would  have  been  more  of  an  epoch  maker  than  a  joke.  Be- 
lieving that  a  most  important  principle  was  involved  in  Brown- 
Sequard's  self  experimentation,  the  author  for  many  years  has  been 
especially  interested  in  the  problem  of  the  normal  equilibrium  be- 
tween sexual  activity  and  age,  and  that  between  general  bodily 
vigor  and  sex  gland  structural  and  functional  integrity.  The  most 
fascinating,  although,  perhaps,  the  least  practical  j)hase  of  the  prob- 
lem, has  been  the  ([uestion  of  the  interrelation  of  senility  and  sex 
gland  activity. 

The  association  of  remarkable  sex  vigor  with  notable  longevity 
is  a  matter  of  common  observation,  even  among  laymen,  btit  which 
is  the  propter  and  which  the  post?  Do  we  age  because  the  sex 
glands  deteriorate  or  do  they  deteriorate  because  we  age?  As  shown 
by  his  report  of  his  experiments  upon  himself  with  the  juices  of  sex 
glands  of  the  lower  animals,  Brown-Sequard  evidently  had  certain 
ideas  of  his  own  upon  the  subject.  Is  there  merely  a  normal,  very 
delicate  equilibrium  between  age  and  sex  gland  activity,  the  mainte- 
nance of  which  determines  whether  or  not  the  individual  wnll  live 
and  preserve  the  vital  functions,  notably  the  sex  powers,  in  active 
condition  to  the  normal  extreme  age  average  ?  Finally,  while  assum- 
ing as  skeptical  an  attitude  as  we  i)lease  toward  the  possibility  of  the 
discovery  of  the  "elixir  of  life,"  may  we  not  —  granting  the  accept- 
ance of  the  "ecpiilibrium"  theory  just  suggested  —  logically  search 
for  a  method  of  restoring  or  preserving  that  eqtiilibrium,  thus  pro- 
longing life  to  its  rare,  normal  conclusion  of  extreme  old  age?  2^Iay 
we  not  even  hope  to  go  beyond  the  limit  of  what  we  now  regard  as 
"extreme"?  Obviotisly,  the  collateral  problems  suggested  are  very 
numerous. 

At  first  sight  the  logical  answer  seems  to  be  that  sex  gland 
activity  is  entirely  dependent  upon  age  and  general  nutrition,  becom- 
ing impaired  pari  passu  with  advancing  age,  to  be  finally  extin- 
guished by  the  degenerescence  of  senility.  In  the  light  of  our  present 
knowledge  of  the  internal  secretions,  however,  are  we  not  justified 
in  suspecting  that  rejuvenation  of  the  supply  of  internal  sex  gland 
secretion  may  have  a  marked  effect  in  retarding  age,  the  disttirbance 

—  207  — 


IMPOTENCE  AND   STERILITY 

of  equilibrium  being  in  favor  of  the  individual  supplied  with  the 
gland  elements  necessary  to  the  formation  of  young  internal  secre- 
tion ?  Admitting  the  cogency  of  this  theory,  who  could  foretell  how 
far  longevity  might  be  prolonged  by  successive  supplies  of  young 
internal  secretion?  We,  of  course,  must  admit  that  anatomic  and 
physiologic  machinery  is  predestined  to  wear  out,  and  whatever  one 
may  think  of  the  future  prospects  of  spiritual  man,  we  must  recog- 
nize his  mortal  limitations. 

Following  the  widely  heralded  alleged  discovery  of  the  "elixir 
of  life"  by  Brown-Sequard,  came  a  host  of  imitators.  These  were 
of  two  classes :  First,  ethical  workers  in  therapeutic  fields ;  second, 
quacks  who  pretended  to  employ  animal  extracts.  Among  the  latter 
was  a  distinguished  American  neurologist,  since  dead,  who  prosti- 
tuted to  commercialism  a  once  enviable  reputation.  His  testine  and 
cerebrine  will  be  recalled  by  many  of  the  older  members  of  the  pro- 
fession. Samples  submitted  to  the  author  direct  by  the  neurologist 
aforesaid  proved  to  be  merely  solutions  of  glonoin. 

Since  the  publication  of  Brown-Sequard's  experiments,  and 
more  particularly  since  the  discovery  of  the  internal  secretions,  the 
profession  has  been  deluged  with  animal  extracts  of  many  kinds, 
manifold  pretensions,  and  varying  degrees  of  harmfulness  and 
therapeutic  efficiency.  Naturally,  much  attention  has  been  paid  to 
sex  gland  extracts.  These  we  will  give  scant  courtesy.  In  the  author's 
opinion,  most  of  them,  up  to  date,  have  been  wrong  in  principle,  toxic 
in  action  and,  aside  from  their  psychic  effects,  absolutely  valueless, 
save  as  sordidly  commercial  propositions.  Recently,  however,  some 
really  scientific  preparations  have  appeared  and  in  some  instances 
apparently  have  given  brilliant  results. 

One  of  the  unfortunate  features  of  organotherapy  is  the  toxicity 
of  animal  extracts  in  general ;  this  with  due  deference  to  the  brilliant 
results  achieved  by  some  of  them.  It  is  logical  to  assume,  also, 
that  the  therapeutic  potency  of  the  best  of  them  is  not  to  be  com- 
pared to  that  of  the  hormones  produced  in  vivo  and  normally  dis- 
charged into  the  circulation.  Some  of  the  various  extracts  of  in- 
ternal secretory  glands  probably  bear  the  same  relation  to  the 
internal  secretions  that  old-fashioned  beef  tea  does  to  wholesome 
beef.  The  nutritive  properties  of  the  beef  do  not  appear  in  the  beef 
tea,  but  the  toxic  elements  do.     As  to  whether  emulsions  of  fresh 

—  208  — 


SEX   GLAND   IMPLANTATION 

material  will  prove  more  satisfactory  than  "extracts"  have  done 
remains  to  be  shown.    The  author  is  optimistic  in  this  regard. 

Since  the  attention  of  the  profession  has  been  so  pertinently 
directed  to  the  internal  secretions,  the  author  has  given  considerable 
thought  to  the  probable  relation  of  sex  gland  secretory  aberrations, 
first,  to  nutrition  in  general ;  second,  to  brain  and  nerve  integrity ; 
third,  to  sex  power  and  activity ;  fourth,  to  senile  pathology  and 
physiology.  The  impression  that  the  well  being  of  all  animals  hinged 
upon  the  integrity  of  the  sex  organs,  and  especially  of  the  testis  and 
ovary,  prevailed  in  very  ancient  times.  The  mechanism  by  which 
the  sexual  apparatus  operates  was  enveloped  in  mystery  until  we 
began  to  comprehend  that  the  procreative  function  of  the  sex  glands 
was  not  their  only  biologic  mission.  The  phenomena  which  for 
centuries  were  known  to  take  place  after  suppression  of  the  secretion 
of  the  sexual  glands  by  castration,  and  by  the  physiologic  change 
incidental  to  the  climacteric,  were  formerly  supposed  to  be  due  to 
"reflex  nervous  action."  It  was  noted  that  the  sexes  were  much 
alike  in  this  respect,  and  it  has  long  been  suspected  that  the  male  has 
a  climacteric,  analogous  to  that  of  the  opposite  sex,  which  occurs 
later  in  life  than  in  the  female,  and  is  attended  by  varying  peculiari- 
ties of  nerve  action.  As  this  is  likely  to  occur  in  the  male  long  before 
fertility  ceases  —  if,  indeed,  we  accept  such  a  climacteric  at  all,  as 
the  author  is  inclined  to  do  —  the  only  rational  explanation  in  the 
light  of  modern  research  seems  to  be  a  diminution  or  change,  or 
both,  in  the  internal  secretion  of  the  sexual  glands,  with,  of  course, 
due  appreciation  of  arterial  changes,  which  themselves  may  be 
merely  secondary.  Still  more  logically  will  this  theory  explain  the 
nervous  phenomena  of  the  menopause. 

In  the  latter  part  of  the  eighteenth  century,  Bordieu  asserted 
that  the  nervous  and  other  morbid  phenomena  which  fol- 
lowed removal  of  the  sex  organs,  and  in  diseased  conditions  affect- 
ing them,  were  due  to  either  a  deficiency  or  superfluity  of  the  pro- 
creative  glandular  secretions.  Bordieu,  however,  had  no  conception 
of  internal  secretions.  Johannes  Aliiller  recognized  certain 
"ductless"  glands.  He  even  designated  the  placenta  as  a  ductless 
gland.  These  glands,  he  believed,  modified  the  blood  which  circu- 
lated through  them,  and  thereby  gave  what  he  called  a  "plastic 
influence"  to  the  generative  circulation. 

—  209  — 


niPOTENCE  AND   STERILITY 

The  testicle  long  has  been  known  to  have  a  double  function,  but 
until  recently  none  knew  that  both  functions  were  secretory.  That 
it  acts  as  a  duct  gland  has  been  accepted  as  long  as  its  physiology 
has  been  known.  In  1849,  Berthold,  of  Gottingen,  transplanted 
the  testes  of  cocks  to  their  abdominal  cavities  and  showed  that  the 
masculine  sex  qualities  were  preserved,  through,  he  averred,  an  effect 
upon  the  blood.  Thus,  without  precise  scientific  knowledge,  and 
with  no  accuracy  of  nomenclature,  Berthold  first  proved  the  exist- 
ence and  significance  of  what  we  now  recognize  as  an  internal  secre- 
tion. Many  years  later,  Forel  asserted  that  "the  implantation 
of  a  sex  gland  in  any  part  of  the  body  is  sufficient  to  arrest  the  pro- 
duction of  the  special  peculiarities  of  the  eunuch,"  and  he  might 
nervous  phenomena  of  the  menopause. 

Since  Berthold's  day,  and  especially  of  recent  years,  consider- 
able experimental  work  has  been  done  in  sex  gland  implantation, 
some  of  which  had  in  view  merely  transplantation  per  se  and  some 
the  matter  of  internal  secretion  in  mind.  A  number  of  the  contribu- 
tions are  worthy  of  special  mention.  Herlitzka,  in  1899,  re- 
ported successful  experimental  transplantations  of  testes  of  frogs 
into  the  peritoneal  cavity  of  the  same  individual.  Later,  Meyns 
successfully  transplanted  portions  of  frog's  testes  into  the  dorsal 
lymph  vessels.  Hammond  and  Sutton  reported  a  case  of  testicle 
transplantation.  A  testicle  was  removed  from  a  subject  who  had 
just  died  of  traumatic  hemorrhage,  due  to  a  rupture  of  the  liver, 
and  placed  in  sterile  salt  solution  in  cold  storage.  A  sarcomatous 
testicle  was  removed  from  a  patient,  twenty-nine  and  a  half  hours 
later,  and  the  testis  from  the  dead  body  systematically  anastomosed 
upon  the  cord  stump.  Healing  was  perfect.  One  month  later,  only 
a  small  nodule  remained  on  the  end  of  the  cord.  Some  time  later 
this  was  observed  to  have  enlarged  a  little,  whether  or  not  from 
return  of  the  sarcoma  has  not  yet  appeared.  The  object  of  the  trans- 
plantation was  a  purely  psychic  effect,  and  no  observations  regarding 
sex  hormone  therapy  were  made.  This  case  obviously  was  a  severe 
test  of  implantation  on  account  of  the  possible,  or  even  probable, 
malignant  involvement  of  the  cord  and  the  anastomosis. 

Foa,  after  extensive  experiments  on  animals,  concluded 
that  testicle  grafts  fail,  merely  because  of  the  impracticability  of 
reestablishing,  by  any  technic  then  known,  blood  and  nerve  supply. 

—  2in  — 


SEX    GLAND   IMPLANTATION 

Guthrie,  however,  found  that  a  testicle  removed  from  a  fowl 
and  planted  in  the  shoulder  of  the  same  bird,  was  growing,  had 
considerably  enlarged,  and  had  acquired  a  liberal  blood  supply  after 
four  months.  He  also  concludes  from  his  experiments  that  "ovarian 
tissue"  from  fowls  engrafted  into  fowls  may  develop  and  preserve 
its  functional  powers  to  a  high  degree."  Cevolotto  found 
that,  after  forty-five  days,  small  pieces  of  testicle  tissue  implanted 
under  the  skin  of  rabbits  showed  changes  which  proved  that  the 
highly  dilTerentiated  cells  of  such  tissues  tend  to  retrograde  to 
ordinary  connective  tissue  cells.  He  notes  an  increase  of  Sertoli  cells 
as  an  evidence  of  degenerescence  of  the  gland  tissue  proper.  In  this 
far,  Cevolotto  is  pessimistic  regarding  the  success  of  sex  gland  trans- 
plantation. 

Lode,  follov/ing  Berthold,  believed  he  had  proved  by  experi- 
ment that  testes  of  fowls  transplanted  beneath  the  skin  retain 
their  vitality  and  functional  activity,  continuing  to  secrete  semen. 
He  also  concludes  that,  in  fowls  at  least,  a  special  secretory  nerve 
supply  for  the  testes  does  not  exist.  Foges,  from  his  experi- 
ments on  fowls,  concluded  that,  while  the  semen  producing  power  of 
transplanted  testes  was  preserved,  their  influence  on  the  secondary 
sex  characteristics  was  not.  This  latter  observation  does  not  accord 
with  the  results  of  certain  recent  experiments  on  fowls  by  the  author, 
although,  as  to  the  end  results,  it  is  too  early  to  arrive  at  definite 
conclusions.  In  human  beings  the  author  has  proved  the  reverse 
to  be  true. 

The  gross  results  of  caponizing  fowls  are  familiar,  even  to  the 
laity.  In  a  series  of  recent  experiments  on  fowls,  the  author  made 
some  interesting  observations  of  the  effects  of  glands  from  non- 
related  birds,  implanted  in  the  capon.  The  nutritive  stimulant  effect 
was  remarkable. 

Ribbert  holds  that  he  has  shown  by  animal  experimenta- 
tion tlie  feasibility  of  transplantation  of  various  living  tissues,  the 
terminal  results  not  being  vmiform  for  different  tissues,  and  resorp- 
tion finally  taking  place  in  all  tissues  save  the  epithelial  structures  of 
the  skin  and  conjunctiva. 

Guthrie  reports  an  experiment  in  which  removal  of  the 
ovaries  resulted  in  the  developnient  of  secondary  male  character- 
istics, the  subject  when  grown  being  spurred,  plumaged  like  the  male, 
])Ugnacious  to  cocks,  and  treading  hens  as  would  a  cock.    The  author 

—  211  — 


IMPOTENCE  AND   STERILITY 

has  observed  a  number  of  supposedly  normal  hens  —  never  experi- 
mented upon  —  which  were  spurred,  given  to  crowing,  pugnacious 
to  strange  cocks,  and  who  would  assume  charge  of  the  flock  of 
hens  and  tread  them  systematically,  as  soon  as  the  cock  was  removed 
from  the  run.  Despite  their  "inversion"  symptoms,  these  hens  were 
good  layers  and  their  progeny  was  normal.  Such  hens  are  familiar 
to  most  breeders  of  domestic  fowl.* 

Claude  Bernard,  in  1855,  called  attention  to  the  glycosuric 
function  of  the  liver  as  dependent  on  a  special  internal  secretory 
action  under  control  of  the  nervous  system.  Brown- Sequard, 
in  1869,  first  expressed  the  idea  that  all  glands,  whether  with  or  with- 
out ducts,  supplied  to  the  blood  a  substance  a  deficiency  of  which 
produced  pathologic  disturbances.  It  was  not,  however,  till  the 
publication  of  his  celebrated  experiments  on  himself  that  attention 
was  given  to  the  question  of  internal  secretions.  In  1889,  at  the  age 
of  seventy-two  years,  he  injected  himself  with  testicular  extract 
from  the  lower  animals.  According  to  his  reports,  he  experienced 
a  marked  improvement  in  mental  activity,  physical  strength,  and 
bowel  action,  and  an  increased  appetite. 

Poehl  states  that  "injections  of  spermine  have  been  given 
to  enfeebled  old  men  who  had  lost  appetite  and  sleep,  and  produced 
improvement  lasting  for  months.  From  the  instances  given,  I  have 
selected  that  of  an  old  lady  of  ninety-five  years,  afflicted  with  severe 
sclerosis  of  the  arteries,  with  no  appetite,  a  bad  digestion,  and  consti- 
pation. This  patient  had  complained  for  several  years  of  sacral 
pains,  and,  moreover,   was  nearly  quite  deaf  and  suffered   from 


*  Apropos  of  plumage  as  a  criterion  of  secondary  sex  characteristics  in 
fowls,  thie  author  takes  the  opportunity  of  observing  that  it  is  not  so  impor- 
tant as  might  be  supposed.  The  hencock,  or  "hennie,"  is  familiar  to  all  game 
fowl  fanciers.  The  plumage  of  the  male  practically  is  the  same  as  that  of 
the  female.  These  fowls  are  vicious  fighters,  some  strains  are  heavy  weights, 
and  all  are  excellent  layers  and  breeders.  The  hencock  often  crops  out  either 
as  a  sport  or  a  throwback  (atavism).  An  observation  of  my  own  may  be  of 
interest.  For  ten  years  the  author  had  bred  a  certain  strain  of  brilliant 
colored,  rich  plumaged,  black  red  game  bantams.  The  originator  of  the  strain 
had  bred  them  for  twenty-five  years.  Neither  of  us  ever  had  made  an  out- 
cross,  but  carefully  preserved  the  type  by  inbreeding  and  lino  breeding.  De- 
siring to  increase  the  vigor  of  the  stock  by  a  change  of  environment,  the 
author  placed  some  of  these  bantams  —  a  full  brother  and  several  sisters  — 
in  the  hands  of  a  very  careful  country  breeder.  In  the  second  year  thereafter, 
four  fine  specimens  of  hencock  appeared  in  the  progeny.  These  the  author 
succeeded  in  perpetuating  fairly  well  by  careful  selection  —  a  difficult  task 
because  the  female  hennie  could  not  be  distinguished  from  her  "regulation" 
.'sisters. 

212  


SEX    GLAND   IMPLANTATION 

periodical  attacks  of  malarial  fever.  The  injections  of  spermine, 
given  for  a  period  of  fifteen  months,  restored  the  old  lady  to  such 
an  extent  that  she  recovered  her  power  of  hearing  and  felt  the 
sacral  pains  only  slightly  and  after  a  long  walk.  Her  general  condi- 
tion was  highly  satisfactory." 

Brown-Sequard's  self  experimentation  is  generally  recognized 
as  the  pioneer  work  in  organotherapy.  The  suggestion  of  the  old 
humoral  pathology,  fathered  by  Bichat,  and  of  the  once  derided 
alleged  vagaries  of  Hahnemann,  which  lingers  about  the  physiology 
and  pathology  of  the  internal  secretions  and  vaccinoserotherapy,  is 
striking,  and  should  appeal  to  the  modesty  of  modern  science.  It 
shows  how  close  the  great  thinkers  of  past  generations  came  to  the 
solution  of  problems  which  a  better  knowledge  of  chemistry,  biolog>', 
and  bacteriology  would  have  made  clear. 

Bayliss  and  Starling  proposed  the  name  hormone,  meaning 
to  awake  or  excite,  for  the  substances  contained  in  those  internal 
secretions  that  affect  the  functions  of  other  organs.  It  appears  that 
continuous  doses  of  some  hormones  are  necessary  to  maintain 
physiologic  activity  at  par.  Presumptive  evidence  of  this  is  shown 
by  the  physiologic  hypertrophy  of  the  remaining  gland  when  one  of 
a  pair  is  removed  or  destroyed.  In  the  case  of  duct  glands,  this,  of 
course,  bears  upon  the  ordinary  secretory  function,  as  well  as  upon 
that  of  internal  secretion. 

That  the  internal  secretions  are  therapeutically  powerful  is 
shown  by  the  brilliant  results  obtained  from  the  administration  of 
thyroid  extract  and  implanted  thyroid  fragments  in  cretinism  and 
allied  conditions  due  to  pathologic  disturbances  or  removal  of  the 
thyroid,  and  by  the  more  recent  observations  on  pituitrin  and  other 
extracts.  That  the  preservation  of  a  very  small  portion  of  thyroid 
tissue  in  thyroidectomy  will  prevent  serious  after-results  has  been 
abundantly  proved.  This  latter  observation  is  also  true,  although 
perhaps  in  less  measure,  of  the  ovary  and  testis.  Paschoud 
also  has  published  some  remarkable  results  from  thyroid  grafting. 
That  even  the  smallest  possible  fragment  of  even  approximately 
normal  ovary  should  be  preserved  in  pelvic  operations,  ought  to  be 
regarded  as  axiomatic.  That  the  same  conservatism  should  be  ex- 
hibited toward  the  male  has  not  yet  dawned  upon  the  majority  of 
surgeons.  When  a  testis  is  condemned  to  removal  in  testicular 
tuberculosis,  and  it  is  possible  to  save  a  small  fragment  of  gland 

—  213  — 


TMPOTKNCE   AND    STKKILITY 

substance,  this  should  l)e  done.  Rarely,  however,  when  the  testis  is 
extensively  involved  and  there  is  suppuration,  is  it  wise  to  leave 
fragments  of  the  organ  in  the  scrotal  sac  on  account  of  the  almost 
inevitable  secondary  tissue  infection.  If,  however,  the  fragment  be 
implanted  in  another  and  easily  accessible  situation,  suppuration  may 
be  avoided  and  the  gland  tissue  is  likely  to  be  preserved.  If  tuber- 
cular infection  should  occur,  it  is  easily  accessible  to  treatment.* 

According  to  Bicdl,  the  hormones  do  not  provoke  the  formation 
of  antibodies.  It  would  appear,  then,  that  any  increased  resistance 
to  infections  that  may  result  from  them  when  used  therapeutically 
would,  of  necessity,  be  indirectly  produced  through  such  stimulating 
or  tonic  effect  as  they  might  have  upon  the  organism  in  general.  The 
question  of  whether  resistance  to  infection  can  be  dissociated  from 
the  formation  of  antibodies  is,  of  course,  not  under  consideration 
here. 

Schiefterdecker's  hypothesis  of  the  physiologic  action  of  the 
specific  internal  secretions  is  very  interesting,  in  that  he  advances  a 
direct  nervous  intervention  as  a  substitute  for  the  old  theory  of  reflex 
action.  He  says :  "Internal  secretion  determines  the  effect  which 
the  products  of  metabolism,  excreted  by  the  nerve  cells  during  the 
simple  processes  of  nutrition,  will  exercise  upon  other  nerve  cells  or 
upon  the  cells  of  the  end  organs,  such  activity  being  called  'trophic' 
It  also  determines  the  effect  which  the  jjroducts  of  metabolism  ex- 
creted in  the  course  of  specific  activity  will  produce,  and  this  effect 
is  known  as  'irritation'  or  'stimulus.'  "  We  will  not  argue  the  point 
of  whether  "irritation"  and  physiologic  "stimulus"  are  the  same. 
The  distinction  seems  too  obvious  —  clinically,  if  not  biologically. 

The  wonders  of  even  the  generative  sex  gland  function  are 
almost  incomprehensible  to  all  but  the  scientist,  who  has  come  to 
accept  them  as  a  matter  of  course.  At  birth  the  ovaries  contain 
something  like  seventy  thousand  ovules,  only  360  of  which  mature 
and  discharge  during  a  normal  menstrual  life  of  about  thirty  years. 
The  real  meaning  of  this  is  staggering.  The  intrinsic  capacity  of 
development  into  a  new  being  under  favorable  conditions  may  be 
assumed  to  be  theoretically  possessed  by  each  and  every  one  of 


*  Dr.  John  F.  Golden,  of  Chicago,  in  a  recent  conversation  informed  the 
author  that,  having  in  mind  the  author's  work,  and  the  conservation  of  the 
patient's  nutrition,  he  had  auto-implanted  in  the  abdominal  wall  a  fragment 
of  testis  from  a  case  of  testicular  tuberculosis  with  apparently  the  best  of 
results. 

-  214  — 


SEX    GLAND   LMPLAXTATTOX 

these  ovules,  and  we  surely  must  grant  creative  potentialities  to  the 
360  ovules  which  mature  and  are  discharged  from  the  ovary.  Every 
one  of  these  mature  ovules,  fertilized  and  transplanted  to  a  favorable 
soil,  would  develop  into  a  new  being.  And  the  fertilized  ovum 
seems  indifferent  to  its  feeding  ground,  whether  peritoneum,  Fallo- 
pian tube,  or  endometrium.  The  embryo  could  come  to  maturity 
on  each  of  them,  were  the  i)urely  mechanic  conditions  favorable. 
Living  blood  —  if  it  is  not  alien  —  with  the  complex  biochemical 
products  that  it  contains,  alone  is  necessary.  The  local  source  of 
the  blood  matters  but  little. 

The  kinetic  energy  of  the  spermatozoon  is  remarkable,  and  the 
movements  thereby  rendered  possible  are  very  active.  It  can  tra- 
verse its  own  length  in  one  second,  an  inch  in  seven  and  a  half 
minutes,  and  the  distance  from  the  ostium  vagiucC  to  the  cervix  in 
about  three  and  a  half  hours.  The  zoosperm  is  indifferent  to 
somatic  death  until  long  after  its  occurrence.  Living  sperm  cells  are 
found  in  the  vagina  eight  days  after  coitus,  and  have  been  found  in 
the  Fallopian  tubes  three  and  a  half  weeks  afterward.  Three  days 
after  the  execution  of  a  murderer,  living  spermatozoa  were  found  in 
the  testes.  In  the  female  bat  they  live  for  months,  and  in  the  queen 
bee  for  three  years.  They  have  been  kept  alive  for  three  days  in  a 
culture  oven. 

The  marvelous  nutritional  and  formative  potentialities  of  the 
generative  secretional  products  of  the  sex  glands  are  proved  by  the 
results  of  the  combination  of  the  spcrmatozoid  and  the  ovule.  The 
combination  of  a  cell  measuring  only  \'-,,„  inch  in  length  with  another 
cell  measuring  V12.-,  of  an  inch  in  diameter  [produces  a  germ  which 
requires  only  a  proper  environment  for  its  development  into  a  new 
being.  Comprehension  of  this  wonderful  biologic  fact  alone  should 
be  sufficient  to  enable  us  to  a])preciate  the  possibilities  of  sex  gland 
secretion  in  therapeutics. 

Both  the  spermatozoid  and  the  ovule  seemingly  must  depend 
inevitably  upon  the  internal  secretor}-  function  of  the  glands  which 
jjroduced  them  for  the  remarkable  results  following  their  combina- 
tion. The  internal  secretory  function  of  the  testis  and  ovary  possibly 
may  in  no  wise  be  dependent  upon  the  generative  glandular  mechan- 
ism but  it  is  hardly  conceivable  that  either  spermatozoa  or  ovules  of 
normal  constitution  can  be  formed  independently  of  the  local  and 
general  nutritional  stimulus  produced  by  the  hormone. 

—  215  — 


IMPOTENCE  AND   STERILITY 

What  is  it  that  imparts  the  formative  energy  to  spermatozoid 
and  ovule  if  it  is  not  the  internal  secretion  acting  through  the  medium 
of  the  blood,  or  directly  upon  the  procreative  glandular  tissue  —  or 
both?  The  vmion  of  sperm  cell  and  ovule  merely  serves  to  make 
dynamic  the  potential  cell  energy  of  each.  The  combination  surely 
develops  a  powerful  nutritional  stimulus.  It  is  by  no  means  im- 
probable that  the  quality  of  progeny  depends  on  the  quantity  and 
quality  of  the  internal  secretion,  both  before  conception  in  both  sexes 
and  after  conception  in  the  female.  Why  may  we  not  hope  to  im- 
prove heredity,  or  even  determine  sex,  by  the  employment  of  internal 
secretion  through  the  medium  of  sex  gland  implantation  or  other 
methods  of  administration?  What  may  we  not  accomplish  thera- 
peutically with  the  vital  energy  of  glandular  organs  which  produce 
such  powerful  biologic  elements  as  the  ovule  and  spermatozoon  and 
in  such  large  quantity  throughout  life,  if  only  we  can  make  that 
energy  do  our  bidding,  as  seemingly  we  can? 

Wliile  the  double  secretory  function  of  the  generative  glands 
has  for  some  years  been  conceded,  the  existence  of  specially  differ- 
entiated histologic  secretory  elements  in  these  important  glands  has 
not  been  so  generally  accepted.  Certain  investigators,  notably  Nuss- 
baum,  have  held  that  the  generative  elements  of  the  glands  produce 
the  hormone.  Others,  again,  have  contended  that  there  is  a  double 
set  of  secretory  elements,  one  of  which  elaborates  the  internal 
secretion  and  the  other  the  generative  secretion  proper.  The  problem 
appears  much  simpler  in  the  case  of  the  ovary  than  in  that  of  the 
testis. 

Prenant,  Born,  and  Fraenkel  showed  that  the  corpus  luteum  is 
epithelial  in  structure  and  possesses  an  internal  secretory  function 
that  is  independent  of  the  generative  function  of  the  gland.  Bouin 
held  that  he  had  demonstrated  that  the  testis  contained,  not  only  the 
obviously  important  seminiferous  tubules,  but  also  other  morpho- 
logically differentiated  elements  of  great  biological  importance  from 
a  secretory  view-point.  Nussbaum,  after  a  series  of  experiments  on 
frogs,  concludes  that  the  influence  of  the  testes  on  sexual  desire  and 
function  is  biochemical  and  acts,  not  only  with  the  glands  normally 
attached,  but  also  when  the  testes  are  isolated  by  cutting  off  their 
nerve  attachments. 

Lespinasse,  before  the  genito-urinary  section  of  the  American 
Medical   Association   in  June,   1913,   reported  a  case  of  impotence 

—  216  — 


SEX   GLAND  IMPLANTATION 

cured  by  "slices"  of  testis,  one  mm.  in  thickness,  taken  from  a  living 
subject  and  immediately  transferred  to  the  scrotum  and  rectus 
muscle  of  a  subject  who  had  been  castrated.  On  the  fourth  day 
desire  and  power  of  erection  returned,  and  had  persisted  for  two 
years  when  the  patient  was  last  seen.  The  same  author  reports  a 
second  case  of  impotence  treated  by  implantation  in  the  scrotal  sac 
of  a  portion  of  testis  from  a  living  body.  Lespinasse's  interesting 
experiments  in  the  already  familiar  field  of  transplantation  of  frag- 
ments of  sex  glands  from  the  living  to  the  living,  bore  no  reference 
to  the  broad  general  subject  of  hormone  therapy  —  save  as  regards 
virility  —  or  of  transplantation  of  sex  glands  from  dead  subjects. 
He  notes,  however,  the  probable  preservation  of  the  interstitial  in- 
ternal secreting  tissue  as  the  explanation  of  his  results.* 

Loisel  showed  by  experiment  that  the  testes  and  ovaries  of  both 
warm  and  cold  blooded  animals  contained  toxic  substances  which 
produced  serious  symptoms  and  even  death,  when  injected  into  frogs 
and  rabbits.  This,  however,  merely  proves  the  existence  of  toxic 
materials  in  extracts  made  from  the  generative  glands,  and,  so  far  as 
it  goes,  in  general  explains  the  frequent  disappointments  and  occa- 
sional harm  of  therapeutically  using  extracts  from  these  tissues.  In 
the  author's  opinion,  Loisel's  observations  have  no  bearing  on  the 
action  of  the  physiologic  internal  secretions  of  a  successfully  im- 
planted sex  gland. 

That  the  mere  passage  of  the  spermatozoa  is  not  necessary  to 
secondary  sex  characteristics  has  been  amply  proved  by  experi- 
mental, accidental  and  pathologic-mechanic  sterilization,  i.  e.,  steril- 
ization which  does  not  destroy  the  spermatozoa-producing  func- 
tion of  the  testis,  but  merely  prevents  their  exit  from  the  gland. 
Obviously,  however,  and  without  questioning  the  fact  that  there  is 
a  double  secretory  function  of  the  testis,  this  alone  does  not  prove 
that  the  spermatic  secretory  tissue  proper  is  not  wholly  or  partially 
responsible  for  secondary  sex  characteristics,  for  spermatic  secretion 
and  resorption  still  continue  after  mechanic  sterilization.  Still  less 
does  it  prove,  when  taken  alone,  that  the  internal  secretion  is  not 
elaborated  and  eliminated  with  the  semen  by  the  tubiili  seminifcri, 


*  The  implantation  of  slices  of  testis  practically  is  a  repetition  of  Leo 
Loeb's  culture  of  tissues  within  the  living  body,  reported  In  Johns  Hopkins 
Hospital  Bulletin,  1898,  and  Proceedings  of  the  Society  of  Experimental 
Biology  and   Medicine,    viii,    1911,    and   Anatomical   Record,    viii,    1912. 

—  217  — 


IMPOTENCE  AND   STERILITY 

or  that  the  tubuh  are  not  necessary  to  perfect  sex  development. 
Neither  does  absence  or  nonformation  of  spermatozoids  mean  that 
the  remaininj^  elements  of  the  semen  are  physiologically  worthless. 
It  has  been  shown  that  a  very  small  amount  of  testicular  or  ovarian 
tissue  is  sufficient  to  preserve  the  secondary  sex  characteristics.  This 
also  does  not  prove  the  relative  unimportance  in  this  regard  of  the 
true  generative  tissue.* 

In  brief,  histologic  secretory  differentiation  having  positively 
been  demonstrated  —  and  disregarding  the  spermatozoids  —  we  still 
cannot  by  it  alone  exclude  the  secretory  function  of  the  true  genera- 
tive gland  tissue  from  what  we  will  term  the  sex  cycle.  The  histologic 
structure  on  which  internal  testicular  secretion  depends  was  termed 
by  Leydig,  "between  cells."  Four  years  later,  Kolliker  described 
them.  In  1903  they  were  termed  by  Bouin  and  Ancel,  in  an  ex- 
haustive treatise,  glande  interstiticlle  du  testicide.  These  cells  are 
situated  in  the  interstitial  tissue  between  the  tubuli  seminiferi  and 
are  of  mesodermic  origin.  Hanes  says  that  the  Sertoli  and  sperma- 
togenic  cells  play  no  part  in  the  internal  secretion,  the  Sertoli  cells 
supplying  fat  to  the  sperm  cells,  the  internal  secretion,  in  all  proba- 
bility being  supplied  by  the  cells  of  Leydig. 

The  physiologic  characteristics  of  these  cells,  and  experimental 
work  on  animals  by  various  investigators,  suggest  the  possibility  that, 
even  where  the  spermatic  tubules  are  "strangled  out"  of  implanted 
testicular  structure  by  subsequent  destruction  and  replacement  of 
generative  glandular  tissue  by  true  connective  tissue,  the  internal 
secretory  function  of  the  implanted  gland  tissue  —  and  hence  such 
therapeutic  efficacy  as  it  may  possess  —  possibly  may  continue  in- 
definitely. 

The  author's  experiments  show  that  the  cells  of  Leydig  actually 
proliferate,  so  that  the  remnants  of  successfully  implanted  glands 
contain  relatively  more  interstitial  cells  than  does  the  normal  gland. 

The  facts  that,  first,  the  semen  is  not  perfectly  elaborated  and 
the  spermatozoa  consequently  are  not  perfectly  formed  imtil  the 
seminal  elements  are  acted  upon  by  the  epididymis ;  second,  that 
destruction  or  removal  of  the  epididymis  does  not  affect  the  secon- 


*  The  relative  unimportance  of  the  spermatogenic  cella  in  the  formation  of 
secondary  ."^cx  character.'?  is  suggested  by  the  author's  experiments.  The  semi- 
niferous elements  atrophy  after  implantation,  yet  there  is  a  marked  action  of 
tlie  remaining  elements  of  the  gland  upon  the  secondary  sex  characters.  (Note 
Cases  1  and   6,   Chapter  XIII. 

—  218  -- 


SKX    CLAXO   niPI.AXTATlOX 

(lary  sex  characlcristics,  and.  ihird.  that  secondary  sex  characteristics 
manifest  themselves  before  either  spermatozoa  are  formed  or  ovules 
matured,  in  a  measure  j^rove  that  the  latter  are  not  dependent  upon 
the  generative  elements,  but  upon  some  special  property  of  the 
glandular  tissue  of  the  sex  glands.  ]\Ioll  says:  "If  it  be  assumed 
that  the  testicles  can  secrete  substances  upon  the  influence  of  which 
the  development  of  the  secondary  sexual  characters  depends,  it  is 
obvious  that  these  substances  have  nothing  to  do  with  the  sperma- 
tozoa, inasmuch  as  the  testicles  exert  the  influence  under  considera- 
tion at  an  age  at  which  the  formation  of  spermatozoa  has  not  yet 
begun.  The  substances  that  act  in  this  way  must  be  of  a  dififerent 
kind." 

]vlarshall  and  Hammond,  in  experiments  on  sheep,  conclude  that 
castration  checks  horn  growth  (a  secondary  sex  characteristic). 
Unilateral  castration  inhibits,  but  does  not  check  horn  growth.  Re- 
moval of  the  testes  without  removal  of  the  epididymes  checks  horn 
growth.  The  authors  accept  the  hormone  theory  of  development  of 
secondary  sex  characteristics.  They  believe,  however,  that  the  role 
of  the  epididymis  in  hormone  production  is  of  little  or  no  importance. 
This  is  not  in  harmony  with  the  observations  of  veterinarians,  who 
have  held  that  preservation  of  the  secondary  sex  characteristics  and 
of  potency  after  castration  is  due  to  failure  to  include  the  epididymes 
in  the  exsection.  Cryptorchidism  is,  of  course,  another  and  a  satis- 
factory explanation  in  some  cases  of  inexpert  castration.  The  author 
has  seen  a  supposed  gelding  repeatedly  cover  mares.  This  animal 
was  said  to  have  retained  his  sexual  power  because  he  was  "castrated 
late." 

The  author's  observations  tend  to  show  that  the  epididymis 
plays  at  least  a  minor  role  in  hormone  production. 

It  has  been  shown  that  the  X  ray  destroys  the  spermatozoa 
producing  function  of  the  testis  without  afifecting  the  secondary  sex 
characteristics.  The  further  observation  that  the  X  ray  primarily 
destroys  the  spermatic  glandular  tissue,  but  does  not  affect  the  inter- 
stitial tissue,  is  held  to  show  conclusively  that  the  latter  is  the  source 
of  the  all  important  internal  secretion.  A  few  tubuli  escape  the 
action  of  the  ray,  and  regeneration  of  the  testis  has  been  shown  to 
occur.  The  question  arises,  however,  as  to  whether  inhibition  of 
the  ])roduction   of   the   delicate   spermatic   cells  —  spermatozoids  — 

—  219  — 


IMPOTENCE  AND   STERILITY 

necessarily  means  that  the  generative  gland  tissue  proper  really  is 
destroyed.  Does  not  the  so-called  "regeneration"  mean  a  restoration 
of  function?  The  author  does  not  believe  that  a  regeneration  of 
killed  tubuli  seminiferi  is  possible.  We  may  profitably  note  what 
occurs  in  the  orchitis  of  parotiditis,  and  reflect  on  how  easily  the 
gland  is  destroyed.  It  also  should  be  noted,  however,  that  when  one 
testis  is  atrophied  by  parotiditic  infection  and  the  remaining  organ 
subsequently  is  lost,  the  secondary  sex  characteristics  are  preserved. 
This  the  author  has  observed  in  one  case.  It  is  quite  as  pertinent  to 
the  subject  in  hand  as  are  the  results  of  X  ray  experiments  and  acci- 
dents. Prolonged  and  repeated  exposure  to  the  ray  will,  of  course, 
destroy  the  entire  structure  of  the  gland  and  produce  effects  similar 
to  complete  castration. 

Summarizing  all  that  is  known  regarding  the  internal  secretory 
tissue  of  the  testis,  Biedl  says :  "We  are  led  to  the  inevitable  conclu- 
sion that  the  hormone  which  gives  to  the  organism  its  male  char- 
acteristics is  elaborated  in  the  cells  of  Leydig,  in  the  interstitial  tissue. 
Despite  their  mesodermal  origin,  these  cells  are  able  actively  to  pro- 
duce certain  specific  substances  and  to  transfer  these  substances  to 
the  blood  stream.  Such  being  the  case,  we  are  justified  in  describing 
them  as  an  'interstitial  gland.'  " 

As  already  hinted,  the  author  is  not  quite  sure  that  Biedl's 
conclusion  is  "inevitable."  It  is  by  no  means  impossible  that  the 
procreative  elements  of  the  testis  themselves  have  a  double  secreting 
action,  the  internal  secretion  being  elaborated  by  the  true  secretory 
glandular  tissue,  and  mainly  taken  up  and  distributed  by  the  blood 
vessels  of  the  organ,  the  excess  escaping  with  the  spermatozoa.* 
Consistently  with  this  hypothesis,  the  internal  secretion  probably  is 
constant,   while  the   spermatozoa   producing   function   is  easily   in- 


*  In  reference  to  this  point,  Waldstein  and  Ekler's  experiments  (Der 
Nachweis  resorbirten  Spermas  im  weiblichen  Organismus;  abstract  in 
Deutsche  medizinische  W^ochenschrift,  October  9,  1913)  are  very  interesting. 
They  found  that  within  two  and  one  half  to  sixteen  hours  after  coitus,  the 
blood  of  the  human  female  contained  a  ferment  which  peptonized  the  albumin 
of  testicular  extract.  Comparing  this  with  Fauser's  observations  in  dementia 
praecox,  we  are  justified  in  suspecting  that  the  internal  secretion  of  the  testis 
is  in  part  eliminated  by  the  semen.  The  marlted  improvement  so  often  noted 
in  the  nutrition  of  sterilized — not  castrated — males,  and  resulting  from  con- 
tinence, thus  may  be  scientlflcally  explained.  It  is  possible,  however,  that 
there  is  a  change  in  the  ovarian  hormone  itself,  under  the  stimulus  of  coitus. 
The  author  believes  that  the  sense  of  well  being  experienced  after  normal 
coitus  by  both  sexes  probably  is  due  to  a  large  dose  of  hormone  entering  the 
circulation  on  the  one  hand  from  the  testis  and  on  the  other  from  the  ovary. 

—  220  — 


SEX   GLAND    [MPI.ANTATION 

hibited  or  destroyed,  and  the  spermatozoa  doubtless  are  more  or  less 
intermittently  produced,  varying  with  sex  stimuli  and  demand.  In 
brief,  the  author  is  not  inclined  to  the  belief  that  the  destruction  of 
the  spermatozcja  producing  function  necessarily  means  complete 
destruction  of  the  true  generative  gland  tissue. 

Biedl  further  says :  "It  is  highly  probable  that,  by  the  agency 
of  its  secretory  products,  this  gland  is  responsible  for  the  develop- 
ment of  the  male  sexual  gland  from  the  differential  genital  tract. 
That  it  has  a  determining  influence  on  the  normal  development  and 
maturity  of  the  generative  portion  of  the  sexual  gland,  the  formation 
of  the  secondary  genital  organs,  and  the  existence  and  persistence 
of  those  morphological  and  biological  characteristics  which  are  the 
])roperty  of  the  male  sex,  is  undoubted." 

The  immediately  foregoing  positive  assertion  of  Biedl's  being 
accepted  as  in  the  main  true,  how  can  we  reject  as  improbable  the 
view  that  a  successful  testicular  implantation  should,  other  things 
being  eqvial,  increase  virility  —  either  by  the  direct  action  of  its 
internal  secretion  upon  the  generative  gland  tissue,  or  (a)  by  enter- 
ing the  blood,  im]:)roving  general  nutrition,  and  (b)  returning  to  and 
acting  as  a  stimulant,  tonic,  and  nutrient  reconstructive  upon  the 
generative  gland  cells?  If  the  internal  secretory  tissue  is  the  self 
elaborated  "meat"  upon  which  the  generative  tissue  jiroper  of  the 
testis  '"feeds,"  aged  and  weakened  glands  should  profit  even  by  an 
increased  supply  alone;  this,  granting  that  an  oversupply  is  im- 
practicable —  as  probably  it  is.  In  connection  herewith,  it  is  note- 
worthy that  advancing  age  and  castration  alike  tend  to  the  pro- 
duction of  obesity.  It  should  be  noted  also  that  obesity,  even  in 
relatively  young  subjects,  is  likely  to  be  attended  by  comparative 
inactivity  of  sexuality.* 

From  the  viewpoint  of  its  internal  secretory  function,  the  ovary 
is  very  similar  to  the  testicle.  The  correlation  of  the  physiologic 
function  of  the  Graafian  follicles  and  of  the  corpus  luteum  has  long 
been  well  known.    The  function  of  the  stromal  gland  cells,  however, 


*  Apropos  of  the  nutritive  .stimulant  action  of  tlie  hormone,  one  of  the 
authoi-'s  own  experiments  is  interesting.  Implantation  of  testes  from  a  year 
old  cock  upon  a  nonrelated  capon  of  the  same  age  resulted  in  an  improvement 
in  carriag'e,  increased  glossiness  of  plumage,  a  better  apjiearance  of  the  face, 
comb,  and  wattles,  increased  liveliness,  and  a  disposition  to  combativeness, 
with  a  sliglit  development  of  sex  activity,  wliich  last  phenomenon  was  of 
short  duration. 

—  221  — 


IMPOTKNCE   AND    STERIIJTY 

has  attracted  attention  only  in  recent  years,  Regaud  and  Policard 
being  the  first  to  suggest  that  these  glandular  cells  might  be  secre- 
tory. Bouin,  in  1902,  described  these  cells  as  glandes  inter stitielles 
de  I'ovaire. 

Biedl  says,  "that  the  secondary  female  sex  characteristics, 
especially  those  of  the  genital  tract,  are  dependent  upon  the  inter- 
stitial cells  of  the  ovary  is  at  present  not  proved."  He  further  directs 
attention  to  the  fact  that  the  X  ray  destroys  the  Graafian  follicles 
alone.  The  interstitial  tissue  is  not  only  preserved,  but  it  hyper- 
trophies. 

While  the  observations  thus  far  made  upon  the  ovary  and  its 
secretions  are  not  as  conclusive  as  in  the  case  of  the  male  gland, 
Biedl  states,  "that  the  tissue  which  performs  the  function  of  external 
secretion  is  also  the  site  of  production  of  the  ovarian  nonsexual 
hormone,  which  exercises  an  alterative  influence  upon  a  large  num- 
ber of  tissues  and  functions,  is  suggested  by  analogy  with  the  male 
sexual  gland." 

This  is  distinctly  contradictory  to  Biedl's  attitude  regarding  the 
testis,  and  his  reasoning  by  analogy  seems  obscure.  In  any  event, 
differences  of  opinion  as  to  the  precise  histophysiologic  source  of  the 
internal  secretion  of  either  the  ovary  or  the  testis  have  little  bearing 
upon  the  experimental  or  therapeutic  value  of  implantation  of  the 
sex  gland  tissues  in  their  totality. 

The  real,  probable,  or  possible  results  of  implantation  of  the 
ovary  depend  —  so  far  as  the  properties  of  the  gland  per  se  are 
concerned  —  upon,  first,  the  existence,  effects,  and  continued  pro- 
duction of  an  internal  secretion ;  second,  the  existence,  effects  and 
continued  production  of  the  ordinary  generative  sexual  secretion ; 
third,  successful  implantation  of  a  normal  gland,  in  whole  or  in  part, 
with  its  structure  entire;  fourth,  the  duration  of  the  life  of  the  im- 
planted gland.* 

Granting  that  the  Graafian  follicle,  the  corpus  luteum,  and  the 
ovarian  interstitial  tissue  are  equally  important,  or  that  only  one  of 
these  tissues  really  is  important  from  the  internal  secretory  stand- 


♦  Stich,  Deutsche  medizinische  Wochensclirift,  September  25,  1913,  in  a 
r6sum6  of  the  present  status  of  organ  transplanting,  sums  up  the  subject  of 
ovarian  transplantation  by  stating  that  it  occasionally  succeeds  in  animals 
which  are  blood  kin.  Stich  altogether  ignores  testicular  transplantation, 
apparently  as  a  subject  on   which   no  data  are   available. 

—  222  — 


SEX    GLAND   IMPLAXTATIOX 

point,  llie  procedures  and  results  should  be  the  same,  unless  it  is  held 
that  a  complexity  of  origin  impairs  the  effects  of  the  gland  secretion, 
which  obviously  it  cannot.  The  first  work  of  any  importance  in 
ovarian  transplantation  from  the  living  was  done  by  Robert  T. 
Morris,  of  Xew  York. 

From  Leo  Loeb's  pioneer  experiments  in  cultivating  tissues  in 
vivo  and  /;;  vitro,  some  years  prior  to  Carrel's  recent  remarkable 
experiments,  the  author  had  suspected  that  niore  or  less  successful 
grafting  of  the  human  testis  from  one  living  subject  to  another  was 
possible.  Aside  from  the  recorded  experiments  on  animals,  this  was 
suggested  by  observation  of  the  effects  of  division  of  the  spermatic 
cord,  exclusive  of  the  vas  deferens,  in  a  large  number  of  varicocele 
operations,  and  experimental  severance  of  the  cord,  including  the 
vas,  in  numerous  hernia  operations  on  old  men  in  a  certain  public 
institution.  In  these  cases  the  author  closed  the  hernial  opening 
over  the  "tucked  up"  proximal  end  of  the  cord,  and  sutured  the 
distal  end  of  the  cord  across  the  ring.  In  respect  to  division  of  the 
cord,  the  procedure  w^as  similar  to  the  operation  for  hernia  later 
suggested  by  Bloodgood.  Early  in  his  surgical  experience  the  author 
found  in  operating  for  varicocele  that,  unless  infection  occurred, 
complete  division  of  the  cord  was  not  followed  by  atrophy  of  the 
testis,  even  when  the  operation  involved  complete  extrusion  of  the 
gland  via  the  operation  incision.  Apparently  the  circulation  of  the 
cord  could  not  be  restored  at  the  point  of  junction  of  the  ends  of 
the  divided  portion  before  the  testis  died  of  innutrition,  if  the 
salvation  of  the  gland  depended  upon  the  spermatic  artery  and  the 
artery  of  the  vas. 

The  vascular  supply  of  the  t\inica  vaginalis  alone  apparently 
being  of  no  magnitude,  the  notion  obtruded  itself  upon  the  author 
that  possibly  comparatively  little  blood  was  really  necessary  to  the 
life  of  the  testis,  and,  further,  that  the  juices  of  the  surrounding 
tissues  might  be  sufficient  to  preserve  the  life  of  the  organ  or  at 
least  a  portion  of  it.  Reasoning  by  analogy,  the  implantations  of 
ovarian  tissue  subsequently  performed  by  various  operators,  in 
which  gland  tissue  from  the  living  was  replanted  in  the  living, 
seemed  quite  conclusive  evidence  of  the  possibility  of  successful 
testicle  grafts  under  similar  conditions. 

With  the  publication  of  Carrel's  remarkable  experiments,  and 
ha\ing  in  mind  not  only  nimierous  experiments  with  tissue  from  the 

—  223  -- 


IMPOTENCE  AND   STERILITY 

living  published  in  the  literature  and  recent  developments  in  the 
study  of  internal  secretions,  but  certain  preconceived  ideas  of  his 
own,  the  author  became  convinced  that  implantation  upon  living-  sub- 
jects of  sex  glands  from  the  dead  body  was  both  practicable  and 
likely  to  be  therapeutically  successful.  He  felt,  also,  that  if  success- 
ful, the  procedure  possibly  might  open  up  avenues  of  medical  and 
surgical  therapy  which  would  be  somewhat  staggering,  even  to 
those  of  us  who  are  not  easy  to  astonish.* 

As  long  ago  as  1913,  the  author  from  time  to  time  endeavored 
to  secure  opportunities  for  experimentation  with  material  from  the 
dead  body  in  sex  gland  implantation  in  both  sexes.  That  the  diffi- 
culty of  obtaining  proper  material  was  great,  should  be  obvious  to 
any  one  who  knows  the  prevailing  sentiment  in  America  against 
using  the  dead  for  scientific  purposes  —  especially  the  recently  dead. 
These  difficulties  were  greatly  enhanced  by  the  fact  that  it  seemed 
desirable  to  secure  glands  from  special  subjects,  of  a  certain  age, 
dead  of  violence,  in  fresh  condition,  and  as  certainly  free  from 
syphilis  as  it  was  practicable  to  determine.  The  Wassermann  test 
might,  or  might  not  be  practicable.  Having  secured  the  proper 
cadaveric  material  for  experimentation,  it  still  remained  to  secure  a 
living  subject  who  would  permit  the  experiment. 

With  the  triple  object  of  experimental  sex  gland  implantation, 
to  determine  whether  it  was  practicable,  for  the  purpose  of 
studying  the  action  of  the  sex  hormone  and  of  testing  the  pro- 
cedure in  the  treatment  of  dementia  prjecox,  the  author  at- 
tempted to  secure  a  favorable  subject  afflicted  with  this  disease, 
and  endeavored  to  enlist  the  cooperation  of  several  medical  friends 
whose  opportunities  for  securing  material  were  better  than 
his,  but  without  success.  The  double  problem  of  securing  human 
sex  glands  under  proper  conditions  and  of  having  a  complaisant  sub- 
ject ready  and  waiting  for  the  experiment  seemed  insoluble,  until  the 
l)lan  of  combining  surgeon  and  subject  suggested  itself  and  the 
author  resolved  to  perform  the  experiment  upon  his  own  person. 

January  16,  1914,  there  were  placed  at  the  author's  disposal  two 
supposedly  appropriate  male  subjects  from  which  to  select  the 
material  necessary  for  gland  implantation.     One  of  these  was  re- 


*  Carrel  liimself  concluded  from  his  observations  that  gland.s  could  not  be 
successfully  transplanted  .save  where  donor  and  recipient  were  kin. 

—   224  — 


SEX    GLAND   IMPLANTATION 

jected.  The  other,  a  suicide  by  gunshot,  and  a  relatively  inferior  but 
apparently  healthy  subject,  eighteen  years  of  age,  was  selected.  The 
subject  had  been  dead  seventeen  hours,  having  lain  at  the  under- 
taker's under  the  ordinary  conditions  and  temperature  since  shortly 
after  death.  The  weather  at  the  time  was  very  mild.  In  the  author's 
haste  to  secure  the  necessary  material,  the  appliances  necessary  to 
secure  blood  for  the  Wassermann  test  were  forgotten,  hence  it  was 
necessary  to  rely  upon  such  history  of  the  subject  as  was  obtainable 
and  a  careful  examination  of  the  body,  especially  of  the  genitals, 
including  incision  and  macroscopic  examination  of  the  lymphatics. 
The  danger  of  syphilis  obviously  could  not  be  entirely  eliminated, 
but  was  not  sufficient  to  weigh  heavily  in  the  balance  of  opportunity 
to  secure  the  long  sought  material. 

Both  testes  were  removed  as  aseptically  as  practicable,  the  in- 
struments and  gloves  being  sterile,  and  iodine  being  freely  employed 
in  lieu  of  the  customary  scrubbing.  The  testes  immediately  were 
placed  in  a  jar  of  sterile  normal  salt  solution. 

Casi;  1.  .iutoi)!iplatitatipii  of  the  testis:  subject  fifty-six  years  nf  age. 
Seven  hours  after  securing  the  necessary  material,  and  twenty-four  hours 
after  the  death  of  the  subject  from  which  it  was  removed,  the  author  im- 
planted in  his  own  scrotal  sac  one  of  the  experimental  testes.  The  operation 
was  performed  in  his  office,  with  the  assistance  of  his  former  associate.  Dr. 
Carl  Aliche!,  whose  hjyaUy  and  intelligent  co-operation  throughout  our 
experiments  cannot  be  too  highly  commended.  The  conditions,  so  far  as 
asepsis  was  concerned,  obviouslj-  were  not  those  of  an  up-to-date  operating 
room,  with  the  usual  corps  of  nurses,  but  were  as  satisfactory  as  was  possible 
under  the  circumstances. 

Technic :  Local  anesthesia  was  employed — a  ten  per  cent,  solution  of 
novocaine  in  one  per  cent,  urea  and  quinine  hydrochloride.  Of  this  about  a 
dram  and  a  half  was  injected.  The  anesthesia  was  satisfactory  so  far  as  the 
skin  was  concerned,  but  by  no  means  so  as  regards  the  deeper  tissues,  merely 
because  especial  care  was  taken  not  to  puncture  the  veins  of  the  cord  and 
also  to  avoid  infiltration  of  the  tissues  about  the  cord  at  the  site  selected  for 
the  implantation. 

The  author  made  an  incision  two  inches  in  length,  in  the  mid-scrotal 
region,  about  an  inch  external  to  the  right  of  the  scrotal  rhaphe,  and  dissected 
down  to  the  cord.  The  awkward  position  nccc--sary  to  the  work  and  the  dis- 
tance of  the  field  from  the  operator's  eye  were  such  that  the  tunica  vaginalis 
inadvertently  was  cut.  The  escape  of  vaginal  fluid  and  the  appearance  of  the 
testicle  at  the  bottom  of  the  wound  gave  the  first  intimation  of  the  accident. 
The  opening  in  the  tnnical  vaginalis  was  closed  with  fine  catgut  and  the 
operation  ])rocccde(l  with. 


SEX    GLAND   IMPLANTATION 

The  author  next  made  beneath  the  deep  fascia  a  pocket  about  two  inches 
in  depth,  at  the  bottom  of  which  was  the  cord.  Into  this  pocket,  directly 
upon  the  cord,  was  implanted  the  testis,  already  prepared  by  removal  of  the 
epididymis  and  decortication  to  the  extent  of  about  half  its  surface.  The 
fascia  was  closed  with  a  pursestring  suture  of  fine  catgut,  following  which, 
bismuth  subiodide  and  the  usual  gauze  dressing  were  applied  and  a  suspensory 
was  adjusted. 

Postoperative  course :  Probably  because  of  undue  movement,  the  ex- 
igencies of  practice  at  the  time  making  it  impracticable  to  rest  physically, 
there  was  a  little  superficial  hemorrhage,  forming  a  small  clot  immediately 
beneath  the  skin  incision.  Saprophytic  infection  occurred,  with  considerable 
edema  of  the  penis  and  scrotum,  extending  well  up  toward  the  inguinal  ring. 
On  the  fourth  day  the  author  opened  the  superficial  portion  of  the  wound, 
drained,  and  aseptized  it.  There  was  not  then  nor  subsequently  any  pus 
infection  during  the  progress  of  healing.  There  was  a  little  over  1°  F.  rise 
in  temperature,  lasting  four  or  five  days. 

There  was  considerable  pain,  following  undue  motion,  on  the  eighth 
day  after  the  operation,  and  a  small  quantity  of  seminiferous  tubules  pro- 
truded from  the  wound,  the  pursestring  fascial  suture  evidently  having  given 
way.  Although  there  was  no  rise  in  temperature  and,  as  already  stated,  no 
pus  infection,  the  author  now  concluded  that  the  experiment  was  a  failure, 
and  decided  to  remove  what  apparently  was  a  somewhat  dangerous  foreign 
body.  He  therefore  requested  Dr.  Michel  to  remove  the  implanted  gland, 
and  as  there  was  a  little  resistance  when  traction  was  made  on  the  protruding 
gland  tissue  at  the  bottom  of  the  skin  (i.  e.,  the  extrafascial  wound),  the 
attempt  was  made  to  remove  it  entire  by  forcible  traction.  The  resistance  to 
traction  and  the  pain  attending  this  procedure  demonstrated  pretty  con- 
clusively that  it  would  have  been  wiser  to  let  the  gland  remain. 

The  gland  splitting  longitudinally,  onlj'  half  of  it,  and,  strange  to  say. 
the  more  solid  portion,  covered  by  the  tunica  albuginea,  came  away.  This,  on 
examination,  showed  well  formed  and  abundant  vascular  adhesions,  which 
apparently  conclusively  showed  that  the  implantation  was  a  success.  We 
therefore  decided  to  leave  the  decorticated  remaining  half  of  the  gland 
/;(  situ.  At  the  time  of  the  implantation  the  semi-decorticated  gland  was  so 
soft  and  so  readily  became  extruded,  that  it  was  with  difficulty  retained  in  the 
implantation  cavity  while  the  pursestring  suture  was  being  inserted  and  tied. 
Had  this  circumstance  been  remembered,  the  mere  fact  that  a  moderate 
amount  of  traction,  or  even  slight  pressure,  was  not  sufficient  to  dislodge  the 
implanted  tissue  from  its  bed  and  extrude  it,  would  have  suggested  the 
wisdom  of  allowing  the  gland  to  remain. 

After  the  removal  of  the  portion  of  gland  there  was  some  increase  in 
the  local  inflammatory  symptoms,  due  to  simple  trauma.  This,  however, 
subsided  within  forty-eight  hours.  Immediately  following  the  removal  of 
the  gland  tissue,  there  was  a  moderate  discharge  of  a  mucosanious  looking 
secretion,  which  continued  in  gradually  diminishing  quantity  for  five  weeks, 
at  which  time  the  sinus  was  completely  healed.     The  tardiness  of  healing  in 

—  226  — 


S1<:X    CI.ANJ)   IMPLANTATION 

a  noninfected  wound  is  worthy  of  note,  suggesting  the  characteristic  of 
fistulae  of  glands  in  other  regions,  notably  the  parotid. 

Numerous  microscopic  examinations  by  Dr.  Michel  of  the  fluid  from 
ihe  fistula  showed  blood  corpuscles,  leucocytes,  and  immature  spermatozoids, 
such  as  normally  are  found  in  the  testis  prior  to  their  complete  elaboration 
in  the  epididymis.  There  was  no  evidence  of  pus  infection,  the  fluid  being 
free  from  pus  cocci. 

After  the  extraction  of  the  portion  of  the  gland,  there  was  no  further 
appearance  of  seminiferous  tubuli  in  the  w'ound,  neither  was  there  any  debris 
nor  broken  down  gland  tissue  in  the  secretion  from  the  "fistula."  After  the 
inflammation  in  the  surrounding  tissues  had  completely  subsided,  a  distinctly 
circumscribed,  ovoid,  insensitive  body  adherent  to  the  spermatic  cord  could 
be  distinctly  felt.  This  mass  measured  approximately  4.5  by  3  cm.  by  2  cm., 
and  was  evidently  composed  of  the  remaining  portion  of  the  testicular  gland 
structure,  with  a  certain  amount  of  new  connective  tissue  investment. 

The  size  of  the  mass  gradually  decreased.  June  1,  1914,  it  was  a  smooth, 
fairly  movable,  ovoid,  insensitive,  circumscribed,  typically  glandular  body, 
about  the  size  of  a  small  almond,  still  loosely  attached  to  the  spermatic  cord. 
August  1,  1914,  the  mass  was  nearly  round,  about  the  size  of  a  hazel  nut  and, 
strange  to  say,  slightly  sensitive.  It  had  not  diminished  much,  if  any,  in  size 
for  several  weeks,  although  still  further  shrinkage  was  expected.  It  was 
noted  that  the  tumor  varied  considerably  in  size  at  different  times.  This 
was  very  suggestive  of  actual  function.  The  "nodule"  gradually  decreased 
in  size  until,  at  the  end  of  eighteen  months,  it  could  barely  be  felt.  That 
during  this  time  the  mass  was  composed  largely  of  proliferated  active 
hormone-producing  cells  the  author  is  firmly  convinced. 

Apparent  Local  Results  of  the  Experimental  Auto- 
Implantation. 

That  the  imi)lanted  mass  was  for  many  months  composed  of 
living,  functioning  testicular  tissue  is,  to  the  author's  mind,  not  an 
open  question.  Dead  tissue  of  such  loose  structure  and  soft  consist- 
ence as  are  the  tubuli  seminiferl,  devoid  of  the  normal  fibrous  enve- 
lopment— the  tunica  albuginca — and  connected  by  an  open  wound 
with  the  surface  of  the  skin,  could  not  los^ically  be  expected  to  re- 
main i)i  situ,  much  less  to  become  encysted  by  connective  tissue,  but 
would  have  broken  down  and  come  away,  either  in  mass  or  as  debris. 
Nor  would  the  sinus  have  healed  so  long  as  necrotic  tissue  was 
present  at  its  tissue  terminus.  If  the  mass  was  purely  inflammatory, 
it  should  not  have  become  circumscribed,  freely  movable  on  its  cord 
attachment,  and  relatively  lasting,  but  should  have  disappeared  pari 
passu  with  the  absorption  of  exudate  in  the  surrounding  inflamma- 
tory area.     The  persistence  of  the  tissue  mass  at  the  site  of  im- 

—  227  — 


IMPOTENCK   AND    STERILITY 

plantation,  together  with  the  continuance  of  the  apparent  physiologic 
results,  appear  to  be  conclusive,  an  opinion  which  was  held  by  all 
who  noted  the  progress  of  the  case. 

As  to  whether  the  implanted  tissue  eventually  would  be  entirely 
destroyed  and  replaced  by  connective  tissue,  the  author  ventured  the 
opinion  that  it  would  not,  holding  that,  if  the  implanted  tissue  finally 
disappeared,  the  temporary  nature  of  the  implantation  result  logic- 
all)-  might  be  explained  by  faulty  technic,  embracing  too  free  decorti- 
cation, which,  as  elsewhere  stated,  in  future  can  be  avoided.  He 
further  believed  that  the  testis  and  ovary,  if  not  completely  decorti- 
cated, would  be  more  likely  to  endure  permanently  after  implanta- 
tion, even  though  considerable  atrophy  occurred,  in  this  respect 
probably  difTering  from  the  thyroid  and  other  glandular  tissues. 

Since  the  original  experiment  it  has  become  evident  that,  in 
most  cases,  complete  atrophy  of  the  implanted  tissue  eventually  oc- 
curs, the  time  at  which  it  occurs  being  variable,  but  in  all  cases  being 
delayed  sufficiently  to  secure  the  benefits  of  the  sex  hormone  for  a 
prolonged  period.  Experience  has  shown,  also,  that  decortication 
really  does  hasten  atrophy. 

If  trophic  nerve  supply  is  essential  to  structural  integrity,  then 
more  or  less  atrophy  of  implanted  gland  tissue  should  be  expected, 
whatever  technic  is  employed,  unless  it  is  conceded  that  regeneration 
of  such  nerve  supply  may  occur. 

The  author  believes  that  he  has  proved  that  apparently  com- 
plete destruction  of  the  generative  portion  of  gland  tissue  does  not 
nullify  the  physiologic  efifects  of  the  implantation.  With  hardly 
perceptible  tumor,  the  Leydig  cells  apparently  still  remain  and  func- 
tion, producing  the  all  important  hormone.  They  seemingly  pro- 
liferate and  may  increase,  in  amount  and  activity,  the  production  of 
internal  secretion.  On  the  other  hand,  they  might  eventually  be  so 
changed  by  blood,  tissue,  and  trophic  influences  as  to  become  inert, 
as  regards  their  internal  secretory  activity,  some  time  before  the 
mass  entirely  disappears. 

In  brief,  whether  or  not  there  is  eventually  apparent  disappear- 
ance of  the  gland  tissue  after  a  successful  implantation,  the  method 
theoretically  should  be  therapeutically  useful  and  its  benefits  perma- 
nent:  First,  because  the  interstitial  gland  tissue  may  remain  and 
function,   producing  hormone ;   second,   because   the  hormone  may 

—  228  — 


SEX    GLAND   IMPLANTATION 

have  (lone  its  work  of  regeneration,  the  conditions  for  which  we 
operated  having-  been  so  profoundly  modified  by  nutritional  changes 
that  they  do  not  recur,  with  consequently  no  indication  for  continu- 
ing the  remedy. 

Although  complete  atrophy  should  be  the  fate  of  implanted 
alien  testes  and  ovaries,  irrespective  of  whether  the  entire  gland  or 
pieces  are  used,  and  suf^cient  benefit  has  not  resulted,  we  still  may 
have  recourse  to  successive  imi)lantations  of  fragments  of  glands, 
repeating  the  "treatment"  as  often  as  may  seem  necessary.* 

vSu(;r.KSTioNs  for  Improvivmknts  in  Tixiinic. 

The  difticulties  under  wdiich  the  author  labored  in  his  auto- 
exj)eriment  require  no  fvu^ther  comment.  That  not  only  the  sex 
gland  implantation,  but  also  the  technic  of  the  process  necessarily 
was  experimental  is  self-evident.  In  his  subsequent  work  the 
procedure  was  modified  by  either  leaving  intact  all  the  tunica  propria 
of  the  testis,  or  decorticating  from  two  to  four  narrow,  longi- 
tudinal surfaces,  about  two  or  three  mm.  in  breadth,  run- 
ning the  entire  length  of  the  gland.  These  narrow  bands  of 
decortication  are  an  extra,  but  probably  unnecessary,  provision  for 
nutrition  by  the  tissue  juices  of  the  implantation  bed  during  the 
formation  of  vascular  adhesions  and  new  blood  supply.  Vascular 
adhesions  naturally  may  be  expected  to  form  at  the  points  of  de- 
cortication. The  limited  area  of  decortication  will  not  subsequently 
permit  of  an  invasion  of  connective  tissue  from  the  surrounding 
structures  sufBcient  to  endanger  the  delicate  glandular  elements  of 
the  implanted  organ.  The  portion  of  the  tunica  albuginea  still  re- 
maining affords  ample  protection  for  the  gland  tissues  beneath  it, 


*  Fre.sh  triturations  of  gland  tissue  even  may  be  u.sed  in  tlie  form  of  an 
emulsion,  injecting  tlie  fluid  almost  anywhere  beneath  the  skin.  Excepting 
implantation,  this  would  seem  to  be  the  most  rational  method  of  administer- 
ing liormone. 

The  danger  of  tlie  phenomena  eliaracteristic  of  anaphylaxis  naturally 
suggests  itself  in  connection  with  successive  implantations  and  testicular 
emulsion  treatment.  Tlie  author  has  implanted  the  testes  of  cocks  repeatedly 
in  the  same  subject,  and  even  in  female  fowls  without  evil  results.  Implanta- 
tion in  fowls  is  a  .severe  test  of  protein  dosing.  If  the  testis  of  the  human 
being  were  as  large  in  proportion  to  the  body  as  that  of  a  lusty  cock,  the 
gland  would  weigh  several  pounds;  this  aside  from  the  relatively  greater 
activity  of  the  glands  of  the  fowl.  The  author  also  has  experimented  upon 
guinea  pigs,  upon  himself  and  upon  a  number  of  otlier  human  subjects  with 
large  doses  of  Iiuman  brain  emulsion,  given  beneath  the  skin  and  intra- 
musru!arl.\',    witliout    injui'\'. 

.  229 


IMPOTENCE  AND   STERILITY 

and  probably  soon  regenerates  and  covers  such  portions  of  the  de- 
corticated area  as  are  not  occupied  by  new  blood  vessels. 

Under  favorable  conditions,  local  anesthesia  is  sufficient  for 
implantation  operations.  In  the  insane,  general  anesthesia  is  likely 
to  be  required,  and  the  author  thus  far  has  employed  it.  Asepsis 
should  be  most  rigid  both  in  securing  the  glands  and  their  implanta- 
tion. The  author  now  removes  them  from  the  dead  body  without 
permitting  his  hands  to  come  in  contact  with  them.  The  glands 
should  be  removed  from  the  body  as  soon  as  possible  after  death. 
The  slightest  degree  of  decomposition  will  insure  failure.  Obvi- 
ously, haste  in  removing  the  glands  is  not  so  urgently  necessary  in 
cold  as  in  warm  weather,  nor  is  it  so  necessary  immediately  to 
implant  the  glands. 

The  glands  should  be  placed  in  sterile  normal  salt  solution,  or, 
preferably,  in  Ringer's  solution,  immediately  on  removal  from  the 
body,  and  under  favorable  conditions  implanted  within  twenty-four 
hours.  As  Carrel  has  shown,  tissues  may  be  kept  frozen  for  several 
weeks  and  still  retain  their  vitality.  This  fact  perhaps  in  future  can 
be  taken  advantage  of  in  preserving  sex  glands  for  implantation. 
In  one  of  the  author's  cases  the  ovary  was  kept  in  a  refrigerator  for 
a  week.  In  a  series  of  cases  which  followed  it,  refrigeration  was 
employed  for  from  two  to  five  days,  but  the  results  were  not  en- 
couraging. 

An  aseptically  prepared  gland,  when  frozen,  can  undergo  no 
change  save  a  certain  degree  of  "autolysis"  which  will  prevent  its 
functioning.  Even  complete  autolysis  would  not  make  dangerous 
the  implantation  of  an  aseptic  gland.  The  autolyzed  tissue  would 
be  likely  to  be  merely  appropriated  as  nutriment  by  the  living  tissues 
of  the  implantation  bed.  It  is  worthy  of  note  in  connection  here- 
with that  the  author's  former  associate,  Dr.  Carl  Michel,  has  ex- 
perimentally demonstrated  that  gland  tissue  kept  at  a  temperature 
of  C)7°  C.  for  about  twelve  hours,  loses  its  functional  activities — 
"functional  autolysis."  This,  he  states,  is  due  to  relative  overfunc- 
tioning  in  the  absence  of  nutriment.  Other  forms  of  autolysis  he 
terms:   (a)  ]'j]iysical ;  (b)  putrefactive. 

The  loss  of  activity  of  the  gland  in  "functional"  autolysis  is 
])robably  due,  Tiot  so  nmch  to  a  lack  of  nutriment  as  to  biochemic 
products  of   the  gland   tissue   itself,  these  products    (both   internal 

—  230  — 


SEX    GLAND   IMPLANTATION 

and  external  secretion)  being  inhibitory  to  the  vitaHty  of  the  tissues 
which  produce  them.  This  involves  a  familiar  principle  in  biolog}% 
particularly  in  pathogenic  germ  biology. 

Excreted  into  and  modified  by  the  blood  after  implantation, 
before  autolysis  has  occurred,  the  gland  products  (secretion)  re- 
turning to  the  gland,  are  stimulant  to  its  function  and  nutritive  to 
its  cells. 

Dr.  Alichel  suggested  that  tissues  designed  for  implantation 
should  be  kept  in  Ringer's  solution  at  a  temperature  not  below  o"^  C, 
and  not  longer  than  two  weeks,  the  object  being  merely  to  inhibit 
the  biochemic  function  of  the  cell  enzymes  without  destroying  either 
them  or  the  cells  that  produce  the  ferment. 

Dr.  IMichel  probably  is  correct  in  his  conclusions,  although  he 
has  overlooked  a  most  important  point  in  his  reasoning,  viz.,  freez- 
ing possibly  may  destroy  the  delicate  cells  of  Leydig  and  the  ovarian 
interstitial  cells  of  Bouin,  without  necessarily  destroying  the  rest  of 
the  gland.  Thus  it  is  not  improbable  that  glands  which  have  been 
frozen  may  sometimes  apparently  survive  implantation  and  yet  not 
function,  especially  from  the  internal  secretory  standpoint.  The 
aim  of  implantation  is  not  to  insert  what  inevitably  must  become 
a  functionless  mass  of  connective  tissue  and  useless  generative  gland 
cells  into  the  body  of  the  recipient. 

The  author  originally  was  inclined  to  believe  that  the  epididymis 
should  be  removed,  where  the  object  is  merely  gland  implantation 
for  experimental  or  for  therapeutic  purposes  to  secure  the  benefits 
of  internal  secretion.  He  said,  in  his  first  paper :  "\\'hile  the 
epididymis  probably  produces  hormone,  it  is  here  of  no  particular 
service,  and  by  its  mere  bulk  and  the  mechanic  irritation  it  produces, 
greatly  enhances  the  danger  of  failure  of  the  implantation.  Again, 
the  removal  of  the  epididymis  afifords  a  surface  favorable  to  ad- 
hesion and  nutrition,  without  extensive  decortication  and  exposure 
of  the  delicate  tubiili  seminiferi."  Subsequent  experience  showed 
that  in  many  instances  it  is  better  to  preserve  the  epididymis. 

The  results  of  anastomosis  of  the  implanted  testicle  thus  far 
have  not  been  very  encouraging.  Very  little  work,  however,  has 
been  done  in  this  direction  on  the  human  stibject,  and  it  seems  to 
be  a  legitimate  field   for  experimentation.     Anastomosis  of  testes 

—  231  — 


T^rPOTENCK   AND    ST]<;RIMTV 

from  closely  related  subjects — especially  from  the  living  to  the  liv- 
ing— at  least  is  hopeful,  despite  the  great  difficulties  attending  anas- 
tomosis of  the  spermatic  vessels. 

When,  for  any  reason,  it  is  desirable  to  attempt  to  preserve 
the  generative  sex  function  of  the  implanted  gland,  the  epididymis 
and  a  portion  of  the  vas  should  be  preserved  for  anastomosis,  a  pro- 
cedure which,  mechanically  at  least,  is  perfectly  feasible — and  suc- 
cessful in  simple  anastomosis  of  the  duct  in  the  living  subject — by 
the  method  devised  by  the  author,  described  in  a  previous  chapter. 
'I'his  method  of  anastomosis  can  be  applied  without  disturbing  the 
cord  or  testis  of  the  recipient  of  the  implanted  gland,  further  than 
to  expose  and  divide  the  vas  deferens  for  anastomosis,  as  shown 
by  several  experimental  cases  of  the  author's. 

The  obstacles  to  anastomosis  of  the  small  vessels  of  the  cord 
appear  at  present  to  be  insuperable.  That  more  or  less  successful 
anastomosis  of  a  testicle  immediately  after  its  removal  from  the 
living  body  is  practicable  in  a  certain  proportion  of  cases,  is  prob- 
able. The  importance  of  this  is  easy  of  comprehension.  There  are 
countries  where  there  are  no  legal  obstacles  to  persons  disposing  of 
portions  of  their  bodies  as  they  see  fit.  Possibly  our  own  laws  may 
one  day  be  amended  so  as  to  enable  us  safely  to  use  gland  material 
from  the  living  that  is  voluntarily  submitted  to  us  by  its  possessor. 
Meanwhile,  if,  as  is  possible,  anastomosis  of  testes  taken  from  dead 
bodies  ever  should  prove  to  be  even  moderately  successful,  some 
wonderful  work  is  likely  to  be  accomplished.* 

That  the  chances  of  failure  of  implantation  are  greater  where 
anastomosis  is  performed  goes  without  the  saying,  as  experiments 
have  not  been  encouraging  and  relatively  free  incision  and  exposure 
of  the  site  of  operation  is  necessary,  and  more  tissue  of  a  lesser 
degree  of  vitality  is  implanted  than  where  our  object  is  merely  to 
secure  the  benefits  of  internal  secretion.  If,  however,  the  gland  it- 
self should  survive,  the  anastomosis  is  not  likely  to  fail.  Here  again 
arises  the  question  whether  Carrel's  results  in  kidney  transplanta- 
tion in  the  lower  animals  are  equally  important  as  bearing  upon  sex 


*  It  should  be  remembered  that  "considerable  atrophy"  of  the  testis  may 
occur,  without  either  the  generative  or  the  hormone  producing  function  of 
the   gland    remnant   being   necessarily   destroyed. 

—  232  — 


SEX    GLAND   IMPLANTATION 

gland  transplantation  in  human  beings.*  Obviously,  rest  in  bed  for 
some  days  should  be  enjoined  in  implantations,  and  for  a  more  pro- 
longed ])eriod  when  anastomosis  is  performed. 

The  site  selected  for  implantation  is  an  important  considera- 
tion, and  should  be  decided  on  the  merits  of  the  individual  case.  It 
may  be  that  the  sex  glands  will  finally  be  shown  to  be  quite  as  suc- 
cessfully implanted  in  one  part  of  the  body  as  another,  but  at  present 
writing  the  author  ventures  to  suggest  that  there  are  ])oints  of  elec- 
tion. In  the  male,  the  site  should  preferably  be  the  neighborhood  of 
the  testis  and  spermatic  cord.  The  tunica  vaginalis  will  invest  the 
implanted  gland  on  one  side,  and  thereby  give  it  in  part  a  natural 
covering.  The  gland  tissue  probably  will  adhere  to  the  tunica  vag- 
inalis more  readily  than  to  the  other  tissues,  and  there  will  be 
very  little  connective  tissue  at  the  point  of  adhesion,  svibsequently 
by  its  contraction  to  menace  the  integrity  of  the  implanted  gland. 
Future  experience  may  show  the  advisability  of  folding  and  stitch- 
ing the  tunica  over  the  gland.  This  possibl}^  would  be  wise  where 
only  a  portion  of  testis  is  implanted.  The  author  would  suggest,  also, 
that  where  only  a  portion  of  the  gland — this  also  applies  to  the  ovary 
— is  implanted,  the  cut  edges  of  the  tunica  albuginca  should  be 
sutured  together  to  protect  the  delicate  gland  tissue  from  connective 
tissue  invasion.  Whether  or  not  there  is  a  special  "selective"  trophic 
or  blood  nutritive  element  in  the  environment  afforded  the  implanted 
tissue  by  the  proximity  of  its  bed  to  the  testicle,  is  an  open  c[uestion. 

Future  experience  may  change  our  view,  but  at  present  it  seems 
doubtful  if  it  would  be  wise  to  implant  the  gland  into  the  cavity  of 
the  tunica  vaginalis.     The  resulting  mechanic  irritation,  conjoined 


*  The  author  feels  that  he  cannot  too  often  insist  that  failure  in  trans- 
plantation of  an  excretory  organ  has  little  Vjearing  on  that  of  a  double  secre- 
tory organ  like  the  testicle  or  ovary.  Carrel  seems  to  believe  that  the  results 
of  his  experiments  should  estop  organ  transplantation  altogether,  judging  by 
his  recent  paper  before  the  American  Surgical  Association.  He  apparently 
loses  sight  of  the  hormone  therapy  angle  of  organ  transplantation.  It  is  to  be 
regretted  that  he  did  not  discuss  this,  more  especially  as  lie  knew  of  the 
author's  own  experiments,  several  weeks  before.  To  have  mentioned  these 
experiments  perhaps  would  have  been  only  fair  to  the  general  scientific  bear- 
ings of  organ  transplantation.  The  author  further  insists  that,  while  the 
preservation  of  the  generative  function  of  tlie  transplanted  ovary  is  not  to  be 
expected — save  possibly  in  testicle  anastomosis  under  the  most  favorable 
conditions — and  that  of  the  testis  possibly  not  at  all,  sex  gland  Implantation 
still  offers  great  therapeutic  possibilities.  As  to  the  local  possibilities,  note 
in  this  connection  the  remarkable  results  obtained  in  several  of  the  author's 
cases. 

—  233  — 


IMPOTENCE  AND   STERILITY 

with  trauma  of  the  sac,  might  produce  so  much  exudation  and 
swelHng  as  to  cause  severe  pain  and  even  endanger  the  recipient's 
own  testicle.  Hydrocele  probably  would  result,  although  this  pos- 
sibly might  be  avoided  by  cutting  "windows"  in  the  sac,  for  drain- 
age. Aseptic  extravaginal  implantation  in  no  way  endangers  the 
subject's  testicle. 

The  second  best  implantation  site  doubtless  is  the  pelvic  pro- 
peritoneal  space,  as  later  will  be  suggested  for  the  ovary. 

As  third  choice  of  location  the  author  would  suggest  the  mons 
veneris,  the  pubis  being  shaved  and  the  incision  made  transversely 
just  below  the  upper  margin  of  the  pubic  hair.  The  length  of  in- 
cision, of  course,  will  vary  with  the  amount  of  fat,  an  incision  one 
inch  in  length  being  ample  in  spare  subjects.  By  the  downward 
insertion  and  opening  of  a  pair  of  forceps  or  blunt  scissors,  a 
pocket  may  by  dry  dissection  easily  be  made  for  the  gland.  This 
pocket  should  extend  dowaiward  to  just  above  the  pubic  symphysis. 
In  this  location,  after  the  hair  again  has  covered  the  part,  neither 
the  scar  nor  the  small  tumor  which  will  result — if  the  implantation 
is  successful — will  cause  comment  by  others.  The  cavity  of  Retzius 
also  is  safe  and  accessible.  The  gland  should  be  implanted  high  up, 
or  well  over  to  one  side  to  insure  peritoneal  contact.  The  axilla 
appears  to  be  another  eligible  location,  the  incision  being  made  well 
away  from  the  centre  of  the  axilla  and  the  bottom  of  the  pocket 
made  to  correspond  with  about  the  centre. 

One  important  difference  between  male  and  female  here  must 
be  noted.  The  former  normally  is  dominated  by  the  psychic  in- 
fluence of  a  testis  that  can  be  seen  and  felt.  He  always  is  conscious 
of  its  presence.  The  reverse  is  true  of  the  female  and  the  ovary. 
The  psychic  benefit  of  the  consciousness  of  a  demonstrable  testis, 
especially  in  the  scrotum,  must  not  be  forgotten  in  the  case  of  the 
male.  It  will  be  by  no  means  a  negligible  quantity  in  external 
ovarian  implantations  in  the  female.  As  to  what  extent  exposure 
to  traumatism  may  militate  against  the  success  of  implantations  in 
exposed  sites  is  a  matter  for  future  determination.  It  is,  however, 
worthy  of  consideration. 

In  ovarian  implantation  of  glands  from  the  dead  subject,  which 
is  quite  as  practicable  as  similar  testicular  implantation,  and  for 
which  the  necessary  glands  of  proper  quality  are  much  easier  to 

—  234  — 


SEX   GLAND  IMPLANTATION 

secure,  the  order  of  choice  of  sites  for  operation  at  present  writing 
appears  to  be  as  follows : 

1.  The  properitoneal  space. 

2.  The  cul-de-sac  of  Douglas  (extraperitoneally). 

3.  The  labiiim  majiis,  the  incision  being  made  high  up  and 
the  part  "pocketed"  downward,  as  in  the  case  of  the  scrotum. 

4.  Beneath  the  mammary  gland. 

3.  The  pubic  region,  as  in  testicular  implantation  in  the  male, 
better,  perhaps,  the  cavity  of  Retzius,  where  observation  of  the  im- 
planted tissue  is  not  desired. 

6.     The  rectus  muscle. 

The  peritoneum  forms  the  normal  environment  for  the  ovary, 
and  if  half  or  n:!ore  of  the  surface  of  the  iniplanted  organ  is  made 
to  rest  iK-rmaneritly  on  the  peritoneum  —  which  by  adhesion  in  suc- 
cessful cases  will  form  a  protective  and  nutritive  investment  for  the 
gland — the  chances  for  success  will  be  greatly  increased. 

An  eligible  point  is  the  ilioinguinal  region,  well  out  toward  the 
anterior  superior  spine  of  the  ilium.  After  exposure  of  the  peri- 
toneum, a  pocket  should  be  made  anteriorly  to  it,  downward  into 
the  pelvis. 

The  cul-de-sac  of  Douglas  is  an  available  and  logical  site  for 
implantation.  A  small  vaginal  incision  should  be  made  posterior  to 
the  uterus,  the  peritoneum  being  carefully  pushed  up  with  the  finger, 
thus  making  a  pocket  for  the  reception  of  the  implantation  gland. 

The  labium  majus  is  a  particularly  eligible  site,  because  of  the 
proximity  of  the  canal  of  Nuck,  which  is  a  peritoneal  derivative  and 
the  analogue  of  the  tunica  vaginalis  in  the  male. 

The  author  will  reiterate  that  a  point  in  favor  of  "exposed" 
sites  of  implantation  in  some  cases  is  the  psychic  efifect  of  objective 
evidences  of  success  on  the  mind  of  the  patient,  which  sometimes 
is  so  desirable.  Incidentally,  the  surgeon  can  more  easily  determine 
whether  or  not  the  implantation  is  successful. 

The  methods  of  Tuffier  an.d  of  Martin  of  implantation  within 
the  pelvis  and  rectus  muscle  of  ovarian  tissue  from  living  donors, 
is  a  procedure  entirely  different  from  that  under  discussion.  Het- 
erointraperitoneal  implantation  within  the  pelvis  is  unnecessary  and 
has  an  clement  of  danger.     For  experimental  jnn-poses  especially,  it 

—  235  — 


IMPOTENCE  AND   STERILITY 

is  usually  best  to  implant  the  gland  in  a  part  accessible  to  observa- 
tion, and  from  which,  if  desired,  it  can  be  subsequently  removed. 
To  imitate  the  natural  environment  as  closely  as  possible,  the  author 
would  suggest  the  experiment  of  partially  wrapping  the  testis  in  a 
graft  from  the  tunica  vaginalis  or  peritoneum,  and  the  ovary  in 
"appendage"  peritoneum,  whenever  the  implantation  site  is  more  or 
less  remote  from  the  normal  ovarian  or  testicular  environment ;  in 
brief,  where  the  environment  would  otherwise  be  alien,  or  possibly 
even  hostile,  it  possibly  can  be  made  temporarily  akin,  or  at  least 
friendly.  Should  the  membranous  lining  of  the  implantation  pocket 
])e  absorbed,  as  is  probable,  it  will  have  served  its  purpose  of  a 
matrix  for  the  growth  of  a  thin  protective  layer  of  connective  tissue. 
A  similar  technic  might  be  advisable  in  thyroid  implantations.  It 
is  probable  that  implantation  in  the  normal  habitat  of  the  thyroid  is 
more  logical  than  elsewhere.  Where  the  tissue  has  no  capsule,  or 
the  capsule  is  insufficient,  fascia  may  be  used  as  a  protective  "cap- 
sule."   Theoretically,  a  piece  of  peritoneum  should  be  ideal. 

Ordinary  connective  tissue  is  a  deadly  foe  of  glandular,  brain, 
and  nerve  tissue,  as  shown  by  its  effects  in  cirrhosis  of  the  liver, 
interstitial  nephritis,  and  various  diseases  of  the  cerebrospinal  axis. 
So  far  as  possible,  therefore,  we  should  protect  the  implanted  gland 
from  invasion  by  it.  It  is  well  to  remember  that  the  environment 
of  the  ovary  is  such  that  it  should  be  removed  from  the  dead  body 
relatively  earlier  than  the  testicle.  The  close  proximity  of  the 
bowel  is  favorable  to  early  decomposition  of  pelvic  fluids. 

In  implantation  in  either  sex,  care  should  be  taken :  First,  to 
make  as  limited  an  incision  as  is  compatible  with  the  insertion  of 
the  gland.  As  the  gland  is  soft,  and  the  skin  and  fascia  elastic,  a 
very  small  incision  will  suffice.  Second,  to  insure  that  the  dissec- 
tion of  the  pocket  shall  be  as  dry  as  practicable  and  to  traumatize 
the  tissues  as  little  as  possible.  Third,  to  avoid  injuring  the  delicate 
gland  tissue  during  its  preparation  and  implantation.  It  should  not 
be  regarded  as  dead  insensitive  tissue  that  may  be  recklessly  mauled, 
but  as  living  tissue  to  be  carefully  handled.  Fourth,  to  use  the  finest 
chromic  gut — or  better,  perhaps,  iodinized  gut — and  insert  no  more 
sutures  than  are  actually  necessary  to  a  perfect  closure.  The  purse- 
string  suture  for  the  fascia  is  ideal.  Fifth,  at  all  times  to  avoid 
rough   mani]nilation    of    the   implanted   gland    during   healing,   and 

--  236  - 


SEX    GLAXD   IMPLANTATION 

especially  to  manipulate  it  as  infrequently  and  as  gently  as  possible, 
while  adhesions  and  vascular  supply  are  forming. 

The  problem  of  the  quantity  of  gland  necessary  for  implanta- 
tion is  a  most  important  one.  If  the  major  premises  herein  out- 
lined— or  suggested — are  correct,  this  problem  practically  involves 
the  question  of  the  proper  dose  of  internal  sex  gland  secretion  in 
various  conditions  and  in  individual  cases.  In  his  first  paper  the 
author  said:  "If  a  fair  average  of  successes  should  prove  to  be 
practicable,  an  entire  testicle  body  is  preferable.  In  general,  how- 
ever, probably  one-half  of  a  testis  is  sufficient  to  give  definite  physi- 
ologic results,  and  is  surer  to  be  preserved  than  a  whole  gland.  In 
the  case  of  the  ovary,  however,  the  author  is  inclined  to  believe  it 
better  to  implant  an  entire  ovary,  even  though  a  small  portion  of  the 
gland  is  seemingly  sufficient  to  preserve  the  secondar)-  sex  character- 
istics and  often  even  to  prevent  the  nervous  wreckage  incidental  to 
oophorectomy."  Further  experience  has  led  to  the  conclusion  that, 
in  the  case  of  the  testis  the  quantity  of  gland  implanted  may  be  varied 
according  to  the  material  used,  small  glands  being  implanted  entire. 

If  the  implantation  is  successful,  the  dose  of  internal  secretion, 
however  large  or  small  it  mav  be,  ])robably  is  continuous  as  long  as 
any  of  the  implanted  tissue  remains.  It  is  for  this  reason  that  a 
relativel}-  small  portion  of  implanted  sex  gland  tissue  is  likely  to  be 
efficacious.  Even  though  implantation  should  prove  successful, 
definite  results  probably  should  not  be  hoped  for  before  six  or 
eight  weeks  after  the  implantation,  at  which  time  complete  estab- 
lishment of  circulation  in  the  gland — if  it  survives — may  reasonably 
be  expected.*  In  general,  it  is  probable  that  such  results  as  may 
occur  will  be  noted  earlier  in  testis  than  in  ovary  implantation,  and 
in  the  case  of  the  testis,  earlier  where  the  gland  has  been  decorti- 
cated, although  complete  decortication  possibly  endangers  permanent 
success.  The  establishment  of  a  sufficient  vascular  supply  is  essen- 
tial, not  only  to  the  life  of  the  gland,  but  to  the  necessary  supply 
of  materials  from  the  blood  for  the  elaboration  of  internal  secretion, 
and  to  the  entrance  of  the  latter  into  the  blood. 


*  In  the  author's  experimental  and  therapeutic  work,  marked  results  have 
occurred  much  earlier.  The  initial  dose  of  hormone  shows  effects  for  the 
first  twenty-four  to  thirty-six  hours.  The  secondary  or  systematic  constitu- 
tional effects  beg-in  within  ten  days  to  tlirce  weeks.  Xew  blood  vessels  are 
found   by   the   eighth   day. 

—  237   — 


IMPOTENCE  AND   STERILITY 
Rationale  oi^  Skx  Gland  Implantation. 

The  story  of  sex  gland  internal  secretion  therapy  can  be  simply 
told.  Tlie  hormone  is  a  cell  stimulant,  nutrient,  and  regenerator. 
The  application  of  the  principle  is,  of  physiologic  necessity,  far 
reaching.  It  may  in  a  measure  serve  to  reconcile  Bichat's  humoral 
pathology  and  the  cellular  pathology  of  Virchow  and  prove  them  to 
be  equally  logical,  but  only  half  truths.  .V  more  highly  developed 
neuropathology  probably  will  be  the  connecting  link  between  them. 
The  germ,  however,  will  not  grow  less  important  in  etiology,  but, 
as  time  goes  on,  undoubtedly  will  be  aggrandized  as  a  causal  factor 
of  disease.  In  brief,  the  micro-organism  will  be  more  clearly  under- 
stood as  merely  the  agency  through  which  most  ])athologic  machin- 
ery is  set  in  motion. 

Should  implantation  ever  become  an  established  therapeutic 
procedure,  as  it  seems  logical  to  predict  that  it  will  be,  it  doubtless 
will  be  found  that  the  required  dose  of  internal  sex  gland  secretion 
will  be  p;overned  by:  1.  The  age  and  general  bodily  vigor  of  the 
recipient  of  the  gland.  2.  The  age  and  presumed  general  and  sexual 
vigor  of  the  dead  subject  from  which  the  gland  was  taken.  3.  The 
disease  and  the  stage  of  disease  for  the  cure  of  which  implantation 
is  (lone.    The  quantity  of  tissue  implanted. 

The  cause  of  death  of  the  donor  is  of  vital  importance.  The 
safest  subject  is  one  dead  of  violence.  Subsequent  experience  may 
show  the  safety  of  using  glands  removed  from  subjects  dead  of 
various  diseases,  notably  nephritis  and  disease  of  the  heart.  Let 
us  hope  for  this,  as  selection  restricted  to  subjects  dead  of  violence 
greatly  limits  the  possible  supply  of  eligible  material.  Subjects  dead 
of  infectious  diseases,  or  affected  by  malignant  disease,  whether  or 
not  it  is  the  cause  of  death,  and  those  of  a  known  cancerous  heredity 
especially,  are  to  be  avoided.  Aside  from  their  dangerous  charac- 
ter, testes  removed  from  subjects  dead  of  general  infection  undergo 
softening  and  decomposition  with  astonishing  rapidity.  In  general, 
subjects  dead  of  either  acute  or  chronic  infectious  disease  are  not 
promising  sources  of  sex  gland  supply,  for  two  reasons:  1.  The 
possible  danger  to  the  recipient ;  2.  the  lack  of  vitality  of  and  the 
rapidity  with  which  at;tolysis  occurs  in  the  glands  from  the  donor. 

It  should  be  borne  in  mind,  however,  that  the  conditions  in 
which  gland  im])]antation  is  indicated  oftcii  arc  such  that  even  con- 

—  238  -- 


SEX    GT^AX])    IMPLAXTATIOX 

siderable  risk  might  be  justified.  On  the  average,  the  dangers  of 
infection  cannot  equal  in  gravity  those  of  the  formidable  surgical 
operations  that  we  daily  perform,  and  implantation  per  se  is  not 
dangerous  to  life.  Perfectly  normal  and  entire  testes  and  ovaries 
are  not  absolutely  essential.  Fragments  of  normal  portions  of  gland 
tissue  taken  from  sex  organs  may  be  utilized,  where  neither  the 
subject  nor  the  gland  is  affected  by  malignant  disease,  tuberculosis, 
acute  or  chronic  infection — purulent  or  other.  When  the  recipient 
of  the  gland  is  known  to  be  syphilitic,  syphilis  in  the  donor  may 
be  disregarded.  It  possibly  may  even  add  to  the  value  of  the 
gland.  The  uninfected  glands  of  patients  dead  of  tuberculosis  are 
likely  to  be  especially  valuable,  if  the  applicability  of  the  method  to 
the  treatment  of  tuberculosis  should  be  proved.  Theoretically,  tuber- 
culosis should  be  found  to  be  an  inviting  field  for  sex  gland  therapy. 
The  only  theory  of  treatment  of  the  disease  that  has  stood  the  test 
of  time  is  that  of  nutrition,  first,  last,  and  all  the  time.  The  in- 
ference regarding  the  indications  for  sex  gland  implantation  is 
obvious. 

In  any  general  bacterial  infection  of  chronic  type  there  is 
systemic  reaction  of  ordinary  glandular,  internal,  and  lymphatic 
secretion.  The  lymphatics,  in  the  attempt  to  filter  the  toxic  sub- 
stances and  the  internal  secretory  glands,  stimulated  to  hyperactivity, 
act  in  combination  with  the  other  defensive  factors  to  overcome  the 
infection.  vSex  glands  taken  from  an  individual  who  has  developed 
a  relative  immunity  to  the  infection  by  means  of  his  natural  physi- 
ologic resistance,  and  thereby  decreased  the  relative  virulence  of  the 
infecting  organism,  theoretically  should  possess,  ccrteris  paribus, 
special  therapeutic  potency.  Transplanted  to  an  individual  suffering 
from  the  same  disease,  the  hormone  of  such  glands  should  increase 
cell  resistance  and  stimulate  to  greater  activity  the  physiologic  nutri- 
tive-defensive cycle,  thereby  aiding  in  overcoming  the  infection. 

In  treating  experimentally  tuberculosis  by  sex  gland  implanta- 
tion, we  therefore  may  use  glands  taken  from  subjects  dead  of  that 
disease.  There  probably  is  little  or  no  danger  of  local  infection  if 
the  glands  are  macroscopically  sound.  The  ovary,  especially,  should 
be  safe,  for  it  rarely  is  affected  by  tuberculosis,  and  even  in  the 
testis  primary  tuberculosis  is  rare.  The  hormone  from  the  internal 
secretion  of  the  implanted  gland  might  be  less  in  quantity  and  in- 

—  239  — 


IMPOTENCE  AND   STERILITY 

ferior  in  quality  to  one  from  a  normal  subject,  yet  potent  enough  to 
restore  the  balance  of  nutritive  defense  against  the  tubercle  bacillus. 

The  excessive  sexual  activity  noted  in  many  victims  of  tuber- 
culosis is  here  worthy  of  consideration.  Is  there  a  relative  excess 
of  gland  activity  with  excess  hormone  thrown  out  as  a  defense, 
with  coincidental  sexual  excitation,  or  is  the  tubercle  toxin  itself  a 
psychosexual  stimulant  ?  The  author  would  suggest  that  the  Fauser- 
Abderhalden  test  might  show  some  interesting  results  in  this  field. 

In  cases  of  complete  castration  in  either  sex,  a  double  implanta- 
tion is  likely  to  secure  the  best  results.  Obviously,  even  admitting 
that  a  single  gland  is  therapeutically  sufficient,  double  implantation 
gives  one  hundred  per  cent,  better  chances  of  success.  In  impotence 
and  sterility  in  the  male,  it  would  seem  rational  to  implant  an  entire 
gland,  not  only  from  the  viewpoint  of  the  dose  of  internal  secretion, 
but  also  becavise  of  the  more  profound  psychic  effect  thereby  at- 
tained. A  successful  anastomosis  possibly  might  restore  the  procre- 
ative  glandular  secretory  function.  In  certain  cases  of  sterility  in 
the  female,  where  the  secondary  sex  characteristics  are  not  marked, 
or  the  general  vitality  is  low  and  there  are  no  mechanic  pelvic  im- 
pediments from  malformation  or  disease,  a  large  dose  of  ovarian 
internal  secretion  possibly  may  stimulate  the  recipient's  ovaries  and 
induce  fertility.  This  also  applies  to  certain  males  in  whom  sper- 
matozoa are  formed,  but  in  whom  they  are  small  in  number  and 
feeble  in  vitality. 

The  age  of  the  subject  from  which  the  sex  glands  are  taken 
for  implantation  is  of  great  importance.  Subjects  from  about  the 
age  of  puberty  to  twenty-five,  or  perhaps  even  thirty  years  of  age, 
are  best,  as  at  this  time  sex  gland  function  is  very  active.  The 
younger  the  subject — below  eighteen  or  twenty  year.s— the  less  the 
danger  of  encountering  syphilis,  and  the  more  active  the  propensity 
for  growth  after  implantation.  Obviously,  the  danger  of  syphilis  is 
relatively  less  at  a  given  age  in  the  female  than  in  the  male.  Glands 
from  subjects  much  younger  than  pubescents  eventually  may  be 
found  to  be  of  especial  value  in  meeting  particular  indications,  more 
especially  as  pubescence  is  not  really  necessary  for  the  production 
of  hormone.  The  author's  best  results  have  been  from  glands  of 
subjects  at  about  the  age  of  puberty. 

Again,  we  possibly  may  secure  good  results  from  the  implan- 

_  240  — 


SEX    GLAXD    IXfPLAXTATTOX 

tation  of  glands  taken  from  subjects  of  relatively  advanced  age. 
Testes  from  donors  of  even  the  recipient's  own  age  at  least  may 
prove  effective.  Advanced  age  is  associated,  not  only  with  a  senile 
quality  of  internal  secretion,  but  also  with  a  relatively  deficient 
quantity.  The  successful  implantation  of  a  single  generative  gland 
logically  would  increase  the  supply  of  internal  secretion  by  one- 
third,  with  proportionate  benefit  to  the  recipient.  The  foregoing 
remarks  apply  especially  to  the  male,  in  whom  the  procreative 
period — and  probably  also  the  internal  sex  gland  secretory  period — 
lasts  much  longer  than  in  the  female.  In  dementia  praecox  and  allied 
conditions,  a  healthy  gland  taken  from  a  subject  at  any  age  below 
middle  life  possibly  may  be  effective,  if,  indeed,  sex  gland  implan- 
tation should  hereafter  prove  to  be  effective  at  all  in  such  cases. 

Racial  distinctions  possibly  need  not  be  drawn  in  procuring 
implantation  material,  unless  anastomosis  is  proposed.  Theoretical- 
ly, sex  gland  activity  is  likely  to  be  greater  in  certain  donors  than 
in  others,  merely  because  of  racial  qualities.  There  is  even  a  serious 
question,  also,  as  to  whether  the  tissue  and  blood  elements  of  the 
recipient  of  the  anastomosed  gland  would  not  eventually  overcome 
any  racial  potentialities  that  might  exist  in  the  implanted  gland.  This 
the  author  found  experimentally  to  be  true  of  skin  epithelium  in 
cross  grafting  skin  in  negro  and  white,  in  1880,  a  result  verified  by 
other  experimenters. 

Tuffier  asserts  that  transplantation  of  the  ovary  from  white  to 
black  and  vice  versa  fails  of  success.  The  author's  experience  in 
this  regard  is  limited  to  a  single  case.  On  March  18,  1914,  he  im- 
planted in  the  axilla  of  a  white  woman  aged  sixty-seven  years, 
afflicted  with  senile  dementia,  an  ovary  from  a  mulatto  woman  of 
forty  years,  dead  eight  hours  of  disease  of  the  heart.  Although 
greatly  shrunken,  the  implanted  gland  apparently  was  still  living 
three  months  later.  Presumably,  while  the  local  results  might  be 
of  briefer  duration  than  in  homotransplantation,  we  still  would 
obtain  adequate  hormone  results. 

That  the  W'assermann  test  should  be  employed  where  practic- 
able goes  without  the  saying.  It  must  be  remembered,  however,  that 
no  more  than  a  single  test  can  be  made  on  a  dead  body,  and  the  test 
alone  cannot  be  relied  upon  to  eliminate  the  danger  of  infection. 
If  it  is  shown  later  that  freezing  of  the  sex  glands  does  not  seriously 

—  241  — 


IMPOTENCE  AND   STERILITY 

impair  the  chances  of  success  in  implantation,  there  will  be  no 
necessity  for  urgent  haste  in  implanting  the  gland,  the  work  can 
be  done  with  deliberation  and  a  Wassermann  test  always  will  be 
practicable. 

The  danger  of  syphilis  is  minirnized  by  the  probability  that 
Treponema  pallidum  lives  but  a  few  hours  after  the  death  of  the 
host.  Freezing  probably  kills  the  protozoon  within  an  hour  or  two. 
If,  therefore,  frozen,  or  even  refrigerated,  glands  should  be  shown 
to  be  satisfactory  for  implantation,  the  danger  of  syphilis  would  be 
practically  nil.  That  refrigerated  glands  are  available  the  author's 
work  has  conclusively  demonstrated. 

In  passing,  the  author  would  suggest  that,  from  the  hormone 
therapy  standpoint,  it  would  be  interesting  to  study  the  results  of 
cross  implantation  of  the  sex  glands  of  male  and  female.  The  ex- 
periment, at  least,  is  practicable.  The  author  reports  herewith 
(Case  VI),  a  case  in  which  he  implanted  a  testicle  in  a  senile  female 
dement.* 

As  to  any  essential  difference  between  the  male  and  female 
sex  gland  hormones  in  their  influence  on  sex  development,  the 
author  has  this  to  say :  The  primary  sex  characteristics  are  probably 
laid  down  in  the  initial  combination  of  the  male  and  female  gen- 
erative gland  secretions — i.  c,  ovule  and  spermatozoon — and  are 
inevitable  phenomena  in  embryologic  development.  The  hormone, 
apparently,  merely  determines  by  its  activities  the  secondary  sex 
characteristics.  Once  these  have  developed,  it  may  be  a  matter  of 
indifference  whether  the  body  cells,  even  those  of  the  sex  glands 
themselves,  are  fed  with  male  or  female  hormone.  Accepting  this 
hypothesis,  the  ovarian  hormone  should  be  therapeutically  effective 
in  the  advilt  male,  and  vice  versa.  Possibly  the  male  hormone  is 
more  powerful  and  likely  to  be  more  effective  than  even  the  ovarian, 
in  the  sex  gland  therapy  of  the  adult  female. 

The  persistence  of  typic  sex  characteristics,  sexual  power  and 
desire  in  animals  castrated  late,  after  the  internal  secretion  has  done 
its  work  —  e.  g.,  geldings  —  is  here  again  worthy  of  note. 


*  Since  this  foregoing  experiment  was  made  the  author's  attention  has 
been  called  to  Steinach's  unsuccessful  experiments  of  ovarian  implantation 
in  castrated  male  animals.  Steinach  makes  no  comments  on  the  hormone 
therapy  usages  of  such  experiments.  (Jahrbuch  6  flir  sexuelle  Zwlschen- 
stufen,    January,    1914.) 

—  242  — 


SEX    GLAND   IMPLANTATION 

Apparent    Physiologic    Effects    of    Testicular    Gland 
Implantation. 

With  due  regard  to  the  difficulty  .of  excluding  the  psychic  ele- 
ment in  therapeutic  experiments,  particularly  as  regards  subjective 
phenomena,  whether  the  experiments  are  of  the  auto  variety  or  the 
hetero  variety,  the  author  will  present  the  apparent  results  of  his  own 
auto-experimentation.  Apropos  of  the  possible  "psychic"  element 
in  his  observations,  several  facts  should  be  remembered :  First,  the 
experiment  primarily  w'as  designed  merely  to  decide  the  question 
of  the  feasibility  of  successful  implantation  of  sex  glands  from  a 
dead  subject ;  second,  the  local  discomfort,  a  certain  degree  of  ap- 
prehension, and  the  inconvenience  resulting  from  the  operation  were 
such  as  tended,  during  the  early  postoperative  period,  to  offset  un- 
due optimism  based  upon  subjective  sensations ;  third,  the  apparent 
results  were  such  as  are  logically  compatible  with  our  knowledge 
of  internal  secretions,  particularly  of  the  sex  glands ;  fourth,  the  im- 
plantation per  se  practically  was  a  success,  even  though  the  gland 
proper  from  biologic  handicaps  did  not  pern:anently  endure;  fifth, 
subsequent  observations  of  numerous  cases  have  verified  the  con- 
clusions to  which  the  auto-experiment  led,  so  far  as  the  effects  of 
the   sex  hormone  on  nutrition  are  concerned. 

The  phenomena  here  recorded  were,  so  to  speak,  "by  results." 
Originally  presented  for  what  they  were  worth,  more  comprehensive 
observations  of  subsequent  work  have  more  than  confirmed  them. 
The  transient  exhilaration  usually  experienced  from  cocaine 
did  not  follow  the  use  of  the  mixture  of  novocaine,  quinine,  and 
urea  hydrochloride.  Despite  considerable  pain  and  some  natural 
apprehension  as  to  local  results,  there  began  at  the  end  of  twenty- 
four  hours  a  marked  exhilaration  and  buoyancy  of  spirits,  lasting 
for  about  twenty-four  hours,  at  which  time  considerable  swelling  of 
the  operation  field  and  adjacent  parts  had  developed.  Possibly  the 
stimulation  experienced  was  merely  delayed  action  of  the  local 
anesthesia.  Later  experience,  however,  apparently  has  shown  that 
it  was  due  to  the  absorption  of  secretions  from  the  semidecorticated 
gland,  which  absorption  temporarily  ceased  synchronously  with  the 
development  of  inflammatory  exudate  about  the  implanted  tissue,  or 
because  of  temporary  exhaustion  of  the  supply,  the  gland  not  having 

—  243  - 


IMPOTENCE   AND   STERILITY 

as  yet  begun  to  function.     This  is  termed  by  the  author  the  "initial 
dose"  of  hormone. 

On  the  seventh  day  after  the  operation  the  author  again  be- 
came conscious  of  stimulation  and  buoyancy  so  marked  that  he  took 
an  undue  amount  of  exercise,  also  attending  the  theatre  in  the 
evening.  It  was  on  the  day  following  that  increase  of  local  dis- 
comfort led  to  an  attempt  to  remove  the  implanted  gland.  Follow- 
ing the  traumatism  incidental  to  removing  half  the  gland,  the  sense 
of  stimulation  disappeared,  to  return  on  or  about  the  tenth  day, 
suggesting  that  the  second  period  of  stimulation  was  synchronous 
with  the  beginning  of  the  establishment  of  vascular  adhesions  and 
consecjucnt  functioning  of  the  gland,  with  absor])tion  of  internal 
secretion,  i.  c.,  what  may  be  termed  the  "secondary  or  physiologic 
dose"  of  hormone.  This  was  checked  by  the  traumatic  reaction  in- 
duced in  the  implantation  bed,  but  recurred  as  soon  as  this  began 
to  subside,  and  was  marked  for  several  weeks,  being  gradually  re- 
placed by  what  might  be  termed  a  normal  consciousness  of  unusual 
physical  and  mental  vigor. 

While  the  sense  of  stimulation  was  at  its  height,  ability  to  en- 
dure physical  and  mental  labor  with  much  less  than  the  usual  amount 
of  rest  and  sleep  was  noted.  This  gradually  lessened,  pari  passu 
with  shrinkage  of  the  implanted  tissue,  but  both  physical  and  mental 
efficiency  still  remained  far  greater  than  before  the  implantation. 

Blood  pressure  seems  to  have  been  greatly  modified.  As 
recorded  by  different  observers  on  two  varieties  of  instrument  it 
gradually  fell  from  140  —  systolic  —  to  an  average  of  125,  at 
which  it  persisted  for  some  months.     At  present  writing  it  is  125. 

The  foregoing  record  is  presented  without  comment,  save  to 
remark  that  the  reduced  blood  pressure  has  been  associated  with  con 
tinuation  of  increased  mental  and  physical  vigor,  and  was  taken  irj 
each  instance  when  the  author  was  working  under  "a  full  head  of 
steam." 

There  was  a  distinctly  perceptible  change  in  the  bloodvessels. 
A  moderately  varicosed  condition  of  the  veins  of  the  legs  and  arms 
markedly  improved.  The  temporal  arteries,  which  had  been  de- 
cidedly and  disquietingly  prominent,  became  indubitably  smaller,  and 
their  walls  softer.  Pari  passu  with  shrinkage  of  the  implanted  tis- 
sue and  diminution  of  hormone  dose,  the  vessels  have  become  more 

—  244  — 


SEX    GLAXl)    IMPI.AXTATIOX 

]}rumincnt.  but  by  no  means  so  prominent  as  before  tbe  experi- 
ment.    There  has  been  no  change  for  some  months  past. 

.\.  decided  change  in  the  heart  action  has  been  noted  in  a  cer- 
tain direction.  For  some  years  frequent  attacks  of  cardiac  irrita- 
bihty  —  probably  due  to  overindulgence  in  smoking,  combined  with 
mental  overwork  and  the  worry  incidental  to  the  exigencies  of 
practice  —  had  been  experienced.  Often  palpitation  on  retiring 
prevented  sleep  for  several  hours.  This  symptom  entirely  disap- 
peared and  has  not  recurred,  save  as  rarely  induced  by  digestive 
disturbance  or  colds. 

While  the  dose  of  internal  secretion  was  at  its  height,  a  very 
])eculiar  symptom  was  noted:  Glasses  which  had  been  comfortably 
worn  for  some  years  seemed  to  be  a  "misfit."  Little  attention  was 
paid  to  this,  however,  there  being  no  suspicion  that  the  ocular  dis- 
turbance bore  any  relation  to  the  results  of  the  experiment.  As 
the  sanie  interesting  phenomenon  occurred  in  the  case  of  ovarian 
transplantation  shortly  to  be  presented,  the  author  concluded  to 
record  it  here.  The  explanation  of  the  symptom  would  seem  to  be 
a  stimulatifjn  of  the  muscles  of  accommodation.  The  condition  is 
still  slightl}-  noticeable.  A  test  of  accommodation  by  Dr.  J.  E. 
Colburn,  ]\Iay  14,  1914,  showed  it  to  be  practically  the  same  as  at 
his  last  examination,  nearly  four  years  before.  There  had  been,  if 
anything,  a  slight  increase  in  the  range  of  accommodation. 

There  was  an  increase  of  ten  poitnds  in  weight  within  about 
eight  weeks.     This  may  or  may  not  have  l)een  significant. 

There  was  an  improvement  in  the  circulation  of  the  skin,  so 
marked  as  to  excite  comment  by  persons  who  had  no  knowledge  of 
the  experiment.  Incidentally,  resistance  to  cold  appeared  to  be 
increased.  The  hemoglobin  record  which  had  ranged  from  ninety 
to  ninety-five  for  some  years,  since  the  implantation  has  been  100 
plus.  As  no  test  had  been  made  for  some  time  prior  to  the  experi- 
ment, this  deserves  no  special  em]:)hasis,  yet  it  might  not  be  amiss 
to  call  attention  to  Case  \'ir. 

The  efi'ect  of  the  implantation  on  the  sexual  function  was 
merely  what  might  have  been  expected  from  local  irritation  of  the 
genitalia  in  any  normal  individual  at  the  same  period  of  life.  As 
to  what  might  result  in  cases  of  impaired  sex  function,  no  deduc- 
tions  could   be   drawn    from   this   particular   experiment,   save   that 

—  245  -  - 


IMPOTENCE  AND   STERILITY 

the  psychic  effect  of  reflex  stimulation  and  the  increase  of  tone 
should  be  markedly  beneficial.     Case  III  is  more  to  the  point. 

As  to  what  might  result  from  a  dose  of  internal  secretion 
larger  than  that  afforded  by  the  portion  of  gland  finally  remaining 
in  situ,  in  a  person  whose  mental  faculties  are  not  under  stress 
and  preoccupation,  a  definite  opinion  would  be  premature,  but 
a  decidedly  stimulating  or  perhaps  permanently  tonic  effect  should 
logically  be  expected,  judging  by  the  report  of  other  cases  of  testic- 
ular implantation  shortly  to  be  recorded,  and  judging  by  our  knowl- 
edge of  the  relation  of  general  well-being  to  sex  vigor,  and  the 
marked  improvement  in  physical  and  mental  efficiency  resulting  from 
a  moderate  dose  in  my  own  experimental  case. 

Supplemented  —  where  indicated  by  the  mechanic  vascular  con- 
ditions —  by  resection  of  the  vena  dorsalis  penis,  as  modified  by 
the  author,  successful  sex  gland  transplantation  should  not  often 
fail  to  relieve  impotence  where  the  sexual  organs  are  properly 
developed  and   serious  brain  or  cord   disease  does   not  exist. 

Brown-Sequard  noted  a  pronounced  stimulation  of  the  func- 
tion of  the  bowel  following  the  self-administration  of  his  animal 
extract.  As  a  victim  of  a  rather  constipated  habit  the  author  re- 
grets that  his  own  experiment  was  not  attended  by  a  similar  result. 

The  author  had  been  annoyed  for  fifteen  years  or  more  by 
marked  keratosis  of  the  soles  of  the  feet,  which,  combined  with 
an  eczementous  condition  of  the  flexures  of  the  toes,  gave  much 
discomfort.  Nothing  seemed  to  benefit  the  condition.  The  idea  of 
curing  it  eventually  was  abandoned,  the  occasional  application  of 
palliative  ointments  being  the  final  recourse.  About  four  weeks 
after  the  implantation  experiment,  the  skin  of  the  feet  had  become 
normal,  with  an  unusually  healthy  color.  By  February  27,  1914,  the 
skin  was  as  soft  and  flexible  as  that  of  a  young  person.  No 
remedial  applications  of  any  kind  had  been  made  for  several 
months.  Possibly  it  may  be  contended  that  the  improvement  in 
the  condition  described  was  nothing  but  a  coincidence,  but  it  cer- 
tainly must  be  admitted  that  it  is  not  incompatible  with  the  probable 
effects  on  nutrition  of  internal  sex  gland  secretion.  (Note  also 
Case  VII.)  Cranting  for  the  sake  of  argument  that  the  change  in 
the  skin  really  was  due  to  the  internal  secretion  of  the  implanted 
gland  —  and  this  the  author  believes  to  have  been  the  true  explana- 

—  246  — 


SEX    GLAND   IMPLANTATION 

tion  —  what  may  we  not  expect  from  the  action  of  internal  secre- 
tion on  the  blood  vessels? 

At  present  writing,  Aug.  1st,  1917,  the  keratosis  has  not  re- 
turned, and  the  skin  is  still  normal,  save  at  the  borders  of  the 
soles,  W'here  in  certain  limited  areas  it  is  dry  and  slightly  eczematous. 

From  the  author's  experience  in  his  own  case  he  is  inclined 
to  believe  that  psoriasis  and  kindred  diseases  are  due  to  perver- 
sion of  internal  secretion.  The  results  of  sex  gland  implantation 
in  Case  VII  have  led  to  the  firm  conviction  that  this  theory  of  their 
etiology  is  well  grounded.  As  to  the  possibility  of  the  cure  of 
certain  chronic  diseases  of  the  skin,  the  general  principle  is  self- 
evident  and  no  comment  is  necessary. 

Carrel  and  Guthrie  assert  that  transplanted  exogenous  glands 
can  function  only  temporarily.  The  kidneys  of  the  cat,  trans- 
planted in  the  same  individual,  survived.  When  transplanted  from 
one  living  individual  to  another,  they  excreted  urine  for  three 
weeks,  at  the  end  of  which  time  they  ceased  secreting  and  the 
animal  died.  This  has  little  bearing  on  the  exogenous  transplanta- 
tion —  at  least  for  therapeutic  purposes  —  of  the  sex  glands  in  the 
human  being.  (See  author's  Case  VI.)  The  sex  gland,  by  virtue 
of  its  internal  and  external  secretory  structures,  is  a  more  highly 
specialized  organ  than  the  kidney.  It  is  also  a  doubly  functioned 
organ.  The  kidney  is  distinctly  an  excretory  organ,  while  the  testis 
and  the  ovary  are  not,  in  the  true  sense  of  the  word.  The  true 
generative  secretion  in  either  sex  is  not  thrown  out  for  elimination 
as  useless  or  toxic  matter,  but,  on  the  contrary,  its  physiologic 
function  does  not  begin  until  after  the  discharge  and  organic  union 
of  the  secretions  of  the  two  sexes.  The  organs  which  produce  the 
generative  secretion  are  more  active,  more  highly  organized,  and 
more  energetic  than  the  kidney.  So  highly  specialized  are  their 
functions  that  no  other  organ  can  act  vicariously  for  them,  as  can 
the  skin  and  bowel  for  the  kidney.  When  the  generative  secretion 
ceases  or  is  prevented  from  escaping  from  the  sex  glands,  the 
organs    still    function    importantly  —  producing   hormone.* 

Again,  as  already  stated,  even  though  the  implanted  gland 
finally    should   perish,    its    work    of    general    cell    regeneration    has 


•  E.  Illlmann,  Annal.s  of  Surgery,  August,  1914,  reports  a  case  of  func- 
tionally successful  anastomotic  transplantation  of  the  kidney  from  one  dog 
to  another. 

—   247   — 


IMPOTENCE  AND   STERILITY 

been  to  a  greater  or  less  extent  accomplished,  with  beneficial  results 
which  may  be  permanent.  Then,  too,  apparent  atrophy  does  not 
necessarily  mean  that  the  interstitial  cells  (Leydig)  are  destroyed. 
Considerable  diminution  in  bulk  even  may  occur  from  various  causes 
without  the  generative  function  itself  being  destroyed. 

That  the  conditions  are  different  in  the  two  varieties  of  gland 
is  shown  by  comparing  the  results  of  Carrel's  and  Guthrie's  lower 
animal  kidney  transplantation  experiments  with  the  author's  own 
autolmman  and  heterohuman  sex  gland  implantations.  Theory 
aside,  the  experiments  related  in  this  volume  have  conclusively 
proved  that,  as  regards  formation  of  new  blood  supply  and  sur- 
vival of  the  hormone  producing  cells  and  internal  secretion  therapy, 
transplantation  of  sex  glands,  even  from  the  dead  body,  is  both 
practicable  and  successful. 

As  to  Carrel's  belief  that  practically  the  only  hope  of  success 
in  gland  transplantation  in  general  is  in  a  close  blood  relationship 
of  donor  and  recipient,  the  author  believes  that,  while  such  relation- 
ship is  highly  desirable,  he  has  proved  that  it  is  not  essential  to 
either  sex  gland  hormone  therapy  via  implantation,  or  to  prolonged 
survival  of  the  essential  elements  of  the  gland.  The  author  has 
further  confirmed  this  view  by  experiments  on  fowls.  It  is  note- 
worthy that  Carrel  and  Guthrie's  conclusions  from  their  experi- 
ments on  the  kidney  of  the  cat,  if  accepted  as  final  in  their  bearing 
upon  gland  implantation  in  general,  would  reduce  to  a  minimum 
the  practicalit}^  of  Carrel's  own  discovery  of  the  persistence  of  tissue 
vitality  after  somatic  death,  so  far  as  its  application  to  the  hormone 
treatment  of  disease  is  concerned.  Apropos  of  implantation  of 
testis  from  distinctly  alien  sources  Guthrie*  reports  a  case  of 
transplantation  of  a  testis  of  a  guinea  fowl  to  the  shoulder  of  an 
ordinary  domestic  cock.  The  implanted  tissue  disappeared.  In 
passing,  it  might  be  interesting  to  Dr.  Guthrie,  if  he  has  not  already 
made  the  observation,  that  it  is  possible  to  crossbreed  the  guinea 
fowl  and  the  .-Vmerican  game  fowl,  hence  they  are  not  as  alien  to 
each  other  as  might  be  supposed.  The  author  saw,  a  little  over  a 
year  ago,  a  bird  —  apparently  a  male  —  so  bred  on  the  farm  of 
Mr.  H.  B.  Gleezen,  the  well-known  game  fowl  breeder,  of  George- 
town, Mass. 


Journal  of   lOxpciiniciital  McHlicinc,   xii,    1!H0. 

—  248  ~ 


SEX   GLAND  IMPLANTATION  -^     -^'^-rsi^ 

The  exogenous  transplantations  of  ovaries  from  the  Hving  to 
the  living  in  sheep  and  guinea-pigs,  reported  by  Voronoff  and  Castle, 
support  Carrel  and  Guthrie's  conclusions,  but  there  still  remain  the 
questions:  1.  Whether  diiterent  results  may  not  occur  in  human 
beings  ;  2.  the  possible  therapeutic  value  of  implantations  of  human 
sex  glands,  with  or  without  permanent  life  and  function  of  the  cells 
of  Leydig,  even  though  generative  gland  tissue  atrophy  inevitably 
should  occur. 

Case  II.  Successful  implantation  of  ovary  from  a  subject  twenty-three 
hours  after  death.  Mrs.  J.,  aged  fifty-nine  years,  suffered  from  the  nerve 
wreckage  incidental  to  a  pelvic  operation  performed  fifteen  years  ago,  and 
also  from  hepatic  and  gouty  disturbances.  The  uterus  and  appendages  were 
removed.  A  "piece  of  the  ovary"  was  said  to  have  been  preserved.  The 
author  explained  to  this  woman  the  objects  and  e.xperimental  nature  of 
ovarian  implantation,  and  she  was  brave  enough  to  submit  to  the  operation. 
Too  much  praise  cannot  be  bestowed  on  her  for  co-operating  in  the  experi- 
ment. 

The  implantation  was  performed  Alarch  3,  1914.  Ovaries,  were  taken 
from  an  apparently  healthy  girl  of  sixteen  years,  a  virgo  intacta,  dead  twelve 
hours  of  skull  fracture.  The  operation  was  performed  eleven  hours  after 
the  removal  of  the  ovaries  from  the  subject,  and  twenty-three  hours  after 
death,  Dr.  Michel  assisting.  One  ovary,  the  left,  was  implanted  in  the  left 
labium  majus,  this  location  being  selected  because  of  the  obesity  of  the 
patient,  and  our  desire  to  study  the  local  results  of  the  implantation.  There 
was  no  marked  tissue  reaction,  only  slight  tenderness,  very  little  pain,  and 
no  rise  of  temperature,  the  wound  healing  by  primary  union.  The  patient 
was  up  and  about  on  the  fifth  day,  reporting  at  the  office  on  the  ninth  day. 
She  might  have  been  up  sooner  but  for  a  persisting  vaginal  prolapse  and 
vesicocele  since  the  operation  of  many  years  ago,  which  required  self-inserted 
tampons  to  permit  locomotion.  May  14,  1914,  the  implantation  appeared  to 
have  been  successful,  the  ovary  was  still  in  situ,  and  of  course,  "living." 
The  case  was  examined  by  several  physicians,  who  found  that  the  ovary 
still  was  plainly'  perceptible. 

It  is  obvious  that  Mrs.  J.'s  case  was  a  severe  test  of  implanta- 
tion. After  fifteen  years  of  neuro]:»athy  and  loss  of  sex  function, 
with  other  disturbances  alien  to  the  latter,  a  great  deal  was  not  to 
be  expected  of  the  method.  A  com])lete  failure  of  therapeutic 
results  would  not  have  disproved  the  efficacy  of  implantation  in 
general.     (The  same  may  justly  be  said  of  Experiments  IV  and  V.) 

Apparent  results  in  Case  II.  Making  due  allowance  for  psychic  effects, 
the  author  will  present  the  report  of  the  patient  and  her  family.  Briefly, 
this  is  as  follows  :  There  was  a  marked  exhilaration  for  the  first  few  days, 
interrupted  one  morning  by  what  the  patient  termed  a  "slight  nervous  chill." 

—  249  — 


IMPOTENCE   AND    STERILITY 

Oil  the  seventh  da^'  she  complained  that  her  glasses  seemed  to  be  no  longer 
effective,  and  that  she  could  not  see  with  them  to  read  or  crochet.  She  then 
asserted,  and  appeared  to  demonstrate,  an  unwonted  flexibility  and  comfort 
of  action  of  her  knees  which,  she  said,  had  been  "stiff  and  lame  for  several 
years."  Her  "hot  flashes"  disappeared.  She  no  longer  experienced  an  almost 
constant  sense  of  exhaustion,  and  arose  refreshed  in  the  morning,  whereas 
she  stated,  she  formerly  arose  as  tired  as  when  she  went  to  bed.  She  stated 
that  she  apparently  needed  less  sleep.  She  was  formerly  annoyed  by  som- 
nolence on  inappropriate  occasions.  This  disappeared.  Having  in  mind  the 
"initial  dose"  of  hormone,  the  author  is  inclined  to  credit  the  patient's  state- 
ments as  to  early  effects.  Blood  pressure  was  not  changed  ten  days  after 
the  operation. 

After  the  first  ten  days,  the  patient  gradually  lost  the  primary  effects. 
March  24th,  however,  she  reported  great  increase  in  physical  endurance, 
stating  that  she  could  climb  three  flights  of  stairs  without  discomfort  or 
cardiac  disturbance.  Formerly  she  was  compelled  to  aid  herself  by  holding 
on  to  the  baluster.  She  reported  again,  great  increase  in  endurance,  with 
improvement  in  the  digestive  functions  and  complete  disappearance  of  the 
joint  stiffness  and  of  a  feeling  of  numbness  and  coldness  in  the  limbs  asso- 
ciated with  uncertainty  of  locomotion  which  had  troubled  her  for  some 
years.  Blood  pressure  still  was  unchanged,  registering  150,  the  same  as 
before  the  implantation.  Complete  relief  of  constipation  of  many  years' 
standing  was  also  reported.  Four  weeks  after  the  implantation,  there  was 
a  marked  change  in  blood  pressure,  which  Dr.  Michel  reported  to  have  after- 
ward ranged  from  125  to  130  (systolic).  On  April  27th,  it  was  125.  May  14th, 
it  was  125.  Two  different  instruments  were  used  in  making  the  record. 
Dr.  Harry  S.  Gradle,  who  had  been  making  a  study  of  Mrs.  J.'s  accom- 
modation, reported  that  it  had  improved  remarkably  while  the  patient  was 
under  his  observation — a  period  of  four  weeks. 

The  patient  made  a  severe  test  of  her  physical  condition  during  her 
spring  housecleaning,  and  experienced  only  the  normal  degree  of  fatigue. 
She  stated  also  that  an  obstinate,  frequently  recurring  bilateral  sciatica  of 
over  thirty  years'  standing  had  entirely  disappeared.  About  July  1st,  she  had 
a  moderate  transient,  unilateral  recurrence,  following  mental  disquiet.  Au- 
gust 1,  1914,  the  improvement  in  the  subject's  condition  still  endured.  The 
implanted  ovary,  although  diminished  in  size,  still  could  be  distinctly  felt. 
Blood  pressure,  vSeptember  10th,  was  128.  The  condition  of  the  1)owe]s  was 
not  so  good  as  at  previous  report,  although  still  better  than  before  the  im- 
plantation. I'ollowing  a  severe  nervous  shock,  the  patient  recently  was  in  a 
very  unsatisfactory  condition.  Later  she  improved,  but  now  is  said  to  be  in 
bad  health,  although  much  better  than  before  the  implantation.  Both  she 
and  her  family  were  so  gratified  by  the  results  of  the  implantation  that  they 
are  anxious  to  have  another  performed. 

Case  III.  A  man,  aged  fifty-eight  years,  commercial  traveler,  who,  for 
a  period  of  five  years  had  been  under  the  author's  care  from  time  to  time 
for  partial  atonic  impotence,  consented  to  submit  to  testicular  implantation. 

—  250  ^- 


SF.X    Gl.AXD    nrPI.AXTATIOX 

There  was  no  local  disease  or  abnormality.  Somewhat  less  than  half  of  a 
testis  was  implanted,  the  material  used  being  obtained  from  the  body  of  a 
man,  aged  thirty  years,  ten  hours  after  death  produced  by  contact  with  a 
live  wire.  The  implantation  was  performed  thirty-six  hours  after  the  death 
of  the  donor.  The  recipient  was  somewhat  neurasthenic,  as  naturally  was 
to  have  been  expected,  but  was  apparenth'  in  excellent  health  and  well  pre- 
served for  a  man  of  his  years. 

The  implantation  was  performed,  March  14,  1914,  Dr.  Michel  assisting. 
The  portion  of  gland  was  partially  decorticated  and  implanted  in  the  left  side 
of  the  scrotum,  in  contact  with  the  cord,  immediately  posterior  to  the  testis 
of  the  recipient,  the  technic  being  essentially  the  same  as  that  employed  in 
my  autoexperiment.  There  was  only  moderate  reaction  after  the  implanta- 
tion. This  had  subsided  by  the  twelfth  day,  at  which  time  a  moderately 
firm,  circumscribed,  movable  mass  of  glandular  outline  could  be  felt  at  the 
site  of  the  implantation.  During  the  process  of  healing  the  patient  expressed 
himself  as  conscious  of  a  remarkable  stimulation  of  sexual  activity.  Accord- 
ing to  his  account  of  the  subjective  symptoms,  this  began  almost  immediately 
— four  or  five  days — after  the  implantation  and  continued  during  the  progress 
of  healing.  Obviously  the  psychic  element  must  be  considered  in  connection 
herewith,  as  there  was  very  little  inflammatory  reaction  and  the  patient  was 
not  at  all  apprehensive  of  accidents.  Nocturnal  erections  began  on  the  second 
night  after  the  operation  and  recurred  regularly  while  he  was  under  my 
observation.  On  the  fourteenth  day  the  patient  left  the  city.  A  letter 
received  from  him,  June  15th,  was  worthy  of  note  merely  as  bearing  upon 
his  condition  at  that  time.  Quoting  this  letter,  the  points  of  interest  are : 
".  .  .  The  erections  at  night  have  continued  regularly.  They  have  rarely 
occurred  before  during  the  past  four  or  five  years.  The  erections  are  not 
quite  as  strong  as  in  my  younger  days,  nor  so  long  continued,  but  the  sexual 
act  is  natural  again  and  is  not  followed  by  great  exhaustion  as  was  formerly 
the  case.  .  .  .  The  lump  where  the  piece  of  gland  was  planted  has  shrunk 
somewhat,  but  1  feel  sure  that  the  gland  is  alive  and  hearty.  ...  I  am 
still  feeling  fine  and  much  more  vigorous  than  I  have  felt  for  years."  The 
evident  improvement  in  this  patient's  sexual  function  cannot  reasonably  be 
entirely  explained  by  the  psychic  effect  of  the  implantation.  Nocturnal 
erections  dissociated  from  erotic  dreams  do  not  occur  from  purely  psychic 
impressions.  As  to  the  influence  of  local  irritation,  this  might  explain  the 
sexual  stimulation  occurring  immediately  after  the  operation,  but  naturally  it 
would  have  subsided  later. 

On  July  20th,  this  patient  presented  himself  for  examination.  The 
implanted  mass  of  gland  tissue  was  still  perceptible  and  about  the  size  and 
shape  of  a  good  sized  almond.  He  asserted  that  the  improvement  in  sexual 
vigor  still  persisted.  No  observations  were  made  of  the  physiologic  effects 
of  the  implantation  in  this  case,  save  to  note  the  blood  pressure — which  was 
165  (systolic),  and  has  thus  far  had  undergone  no  change — and  to  examine 
the  semen  microscopically,  which  was  normal,  July  20th. 

January    15,    1915,    the   patient   again    reported.      The   implanted    nodule 

—  251  — 


iaipoti<:nce  and  steiiility 

had  almost  disappeared,  but  was  still  perceptible  on  careful  palpation.     Im- 
provement had  been  maintained  and  the  patient  was  very  enthusiastic. 

December  29,  1916,  the  patient  reported  himself  as  still  doing  well,  and 
very  much  pleased  with  the  results  of  the  implantation. 

In  a  recent  letter  he  claims  to  be  still  satisfied  with   results. 

Febrtiary  21,  1914,  the  aitthor's  attention  was  called  to  a 
masterly  paper  by  Dr.  Bayard  Holmes,  of  Chicago,  "The  Non- 
mental  Character  of  Dementia  Praecox."  It  was  interesting  to  note 
that  Fauser's  experiments  in  the  diagnosis  of  dementia  prsecox  and 
allied  conditions,  which  experiments  had  not  previously  been 
brought  to  the  author's  attention,  were  complementary  to  the 
theory  on  which  he  had  been  working,  in  endeavoring  practically 
to  administer  internal  sex  secretion  in  various  conditions.  Follow- 
ing Abderlialden's  theory  of  "dysfunction,"  Fauser  found  that  the 
Abzvelirfenneut  or  defensive  ferment  in  the  blood  of  patients  with 
dementia  prsecox  reduced  the  antigenlike  material  made  respectively 
from  the  testicle  or  ovary,  according  to  the  sex  of  the  patient.  He 
finally  established  his  test  as  a  reliable  diagnostic  procedure.  Sum- 
ming up  his  studies  of  the  Abderhalden  test  and  its  application  to 
the  insanities,  Holmes  says : 

1.  The  evidence  accumulated  taken  with  many  other  factors  indicates 
that  dementia  prsecox  is  a  condition  or  disease  in  which  the  secretions  of  the 
genital   glands   are  greatly  perverted. 

2.  As  a  part  of  this  disturbance  of  the  balance  of  the  internal  secre- 
tions, many  other  glands  are  coincidentally  disturbed. 

3.  This  "dysfunction"  of  the  genital  glands  may  be  and  is  likely  to  be 
due  to  various  peripheral  infections,  such  as  are  found  to  produce  dysfunc- 
tion of  the  thyroid. 

4.  The  Abderhalden  reaction  promises  a  method  of  diagnosis  which 
can  be  applied  early,  in  pedagogic  and  penal,  if  not  judicial  laboratories. 

5.  The  psychogenetic  theory  of  dementia  ought  to  stand  aside  and 
give  way  to  research  into  physical  conditions  and  etiological  factors  and 
methods  of   prevention  and   cure. 

6.  Every  institution  that  makes  any  pretense  to  psychiatry,  even  every 
reformatory  for  juvenile  offenders,  male  or  female,  should  have  a  laboratory 
fitted  out  for  the  defensive   ferments  reaction. 

Adding  to  the  list  of  causes  of  dysfunction  imperfect  or  aber- 
rant sex  gland  development,  leading  to  dementia  prcecox  and  allied 
conditions,  the  etiologic  picture  is  complete. 

I>i  the  light  of  Fauser's  observations,  the  conclusion  is  obvious 
that  the  logical  indication  in  dementia  prcccox  is  the  administration 

—  252  — 


SI-.X    CI.AXl)    IMIM.AXTATIOX 

of  mtcnial  sccrctiuii.  or  a  comhiinitioii  of  secretions,  hi  iiitf'hnita- 
lioii  of  sc.v  (jhmds  -wc  iuvvc  llic  iitosi  Uxjical  mclhod  for  the  odniiiiis- 
tralioii  of  probably  the  iiiosi  iniporlaiit  of  all  the  iiilenial  seereti(>)is 
ill  llie  field  of  psychiatry. 

If  the  essence  of  the  etioloi^y  of  denientia  ])r;ecox  reaUy  is  a 
(l_\'sfiniction  of  the  sex  ,<^'!an(ls.  then  tlie  in(hcations  are  esiieciahy 
clear  and  lo<4icaL  It  must  l)e  remenihered.  however,  tliat.  ahhou.yh. 
it  is  c(jnceded  that  the  indications  for  sex  gland  implantation  seem 
to  l)e  especially  clear  in  dementia  prjecox.  h\'  the  time  the  diagnosis 
is  made,  considerable  organic  netn^on  change  mav  have  occttrred. 
with  a  restilting  permanent  aberration  of  function.  Cnlike  other 
lirgans.  compen>ator\-  actifjn  of  ])rain  cells  ])robal)l\'  will  not  (jccur 
and  conserve  its  mental  functions.  A  moderate  im])airment  of  the 
structure  of  the  hepatic  or  of  the  renal  cells  mav  not  be  manifested 
by  any  ap])arent  change  in  the  health  of  the  subject.  In  the  case 
of  the  kidney,  vicarioits  acti(jn  of  other  eliminative  areas  may  in- 
definitely keep  tlie  subject  in  apparently  good  health.  The  slightest 
impairment  of  the  delicate,  highly  specialized  brain  netiron  strticture 
almost  inevitabl}-  will  l)e  followed  by  a  greater  or  less  degree  of 
luental  deterioration. 

The  hebe])hrenic  tyjje  of  dementia  pr^ecox  jjrobably  is  the 
mrjst  ])romising  one  for  honuone  thera])}'.  While  diseases  of  the 
nervous  system  in  general  seeiu  to  be  a  ])romising  field  for  sex 
gland  secretion  theraj)}",  early  administration  is  tirgentlv  necessarx' 
to  give  b(jth  the  ])atient  and  the  remed\'  a  fair  chance.  Kegeneration 
of  strtictttrall}'  damaged,  delicate  neuron,  nerve  hl)re,  and  ganglion 
cell  is  rather  more  tlian  can  fairh'  be  ex])ected  of  an}'  remedv. 

fn  the  earl\-  stages  of  kjcomotor  ataxia  and  ])arcsis,  im])lantation 
seems  to  be  worthy  of  trial.  The  disastrotis  effects  of  the  spirochete 
are  largely  due  to  the  cell  toxemia  it  produces,  and  to  the  pressure 
of  vasctilar  cell  intiltraticjn.  The  resttlting  damage  is  of  a  ntttri- 
tional  ty])e.  and  the  indications  seem  to  be  clear  enough. 

Chronic  inel)riet_\'  offers  considerable  inducement  for  sex  gland 
therapy.  The  innutrition  and  nerve  instabilit)'  which  cause  the  cell 
to  "cr}'"  for  alcohol.  (|uite  likeh'  can  ])e  met  Ijv  the  hormone  of  the 
sex  gland  secretion,  administered  in  one  form  or  another,  preferably, 
l)erha])S,  b\-  im])lantation. 

C.iven  a  reiuedy  which  really  stinnilates  the  nutriticni  of  nerve 

-~  2??>  — 


I.Ml'OTKNCI-:    AND    STl-RfUTY 

tissue,  and  the  ])()ssibilitic's  of  scr\icc  in  tlicra])}-  arc  boundless. 
There  are  few  chronic  ch'seases  in  \\hicli  the  nervous  s\'steni  is  not 
more  or  less  involved,  with  resultant  trophic,  sensorw  or  motor 
pertttrbation. 

Apropos  of  the  ])ossible  benefit  of  internal  sex  gland  secretion 
in  arterial  conditions  in  which  sy])hilis  is  the  primary  etiologic 
factor,  the  analogy  between  senile  and  sy])hilitic  vascular  changes 
is  suggestive. 

In  enlarged  prostate,  benetit  possibly  might  occur  from  sex 
gland  implantation  through.  1,  relief  of  the  senile  etiologic  element 
through  improved  nutrition  ;  2,  antagonism  to  the  bacterial  infection 
element  —  gonococcic  or  colon  —  which  is  such  an  important  etio- 
logic factor  in  ])rostatism ;  3.  resolution  of  the  adventitious  (in- 
flammatory) tissue,  more  or  less  of  which  is  found  in  the  enlarged 
prostate. 

In  dementia  priecox  the  etiologic  possibility  of  syphilis  should 
be  seriously  considered  before  resorting  to  implantation.  Here  the 
Wassermann  test  is  of  great  service.  Syphilis  unquestionably  is 
res])onsible  for  some  cases  of  dementia  ])r;ecox,  or  at  least  of  a 
certain  ])roportion  of  cases  which  fall  symptomatically  under  that 
nomenclature.  The  author  ((ualifies  merely  becaitse  the  Fauser- 
Abderhalden  test  mav   force  the  adoption  of  a  new  nomenclature. 

In  a  case  of  alleged  dementia  praecox  in  a  boy  of  twenty  years, 
seen  about  five  years  ago,  in  consultation  with  a  most  competent 
alienist,  the  aitthor  diagnosed  syj^hilis.  The  Wassermann  test  proved 
negative.  No  history  of  .sy])hilis  had  been  recorded.  During  a 
fairly  lucid  interval,  the  patient  finally  related  an  escapade  of  intoxi- 
cation and  ex])osure  to  infection,  a  ])romptlv  and  mistakenly  cauter- 
ized ])enile  sore  of  brief  duration  ap])earing  later.  Careful  ins])ection 
showed  a  fairly  ty])ic  adeno])ath}'  and  a  s])arse,  fading  maculo- 
])a])ular  sy])hilide.  The  ])atient  recovered  under  s])eciiic  medication 
and  now  is  a])parently  ])erfcctly  well.  As  a  ])resumptive  verification 
of  the  diagnosis,  a  retinal  or  choroidal  hemorrhage  occurred,  un- 
doubtedly because  of  neglect  of  treatment,  some  nK)nths  ago.  de- 
stroying the  vision  of  tlie  affected  e\e. 

It  ma\'  be  remarked  that  s\'])hilis  in  the  reci])ient  ought  not  to 
be  regarded  as  a  contraindication  for  inii)lantation.  The  disease 
may  act  as  other  infective  diseases  ap])arentl\'  do,  by  a  toxic  influ- 

—  254  — 


SEX    GLAXI)    IMPLAXTATIOX 

cnce  on  the  internal  secretory  function  of  the  sex  glands.  Anti- 
syi)hilitic  treatment  is  indicated,  but  the  impression  made  by  the 
infection  upon  the  sex  glands  luay  be  such  that  treatment  is  ineffect- 
ive.    Here  gland  implantation  is  worthy  of  trial. 

v^enile  cataract  and  its  associated  conditions  in  their  incipiency 
are  an  attractive  tield  for  experimental  work  with  sex  gland  hormone 
via  implantation. 

v^hould  sex  gland  implantation  prove  even  moderately  effective 
in  checking  or  im])ro\-ing  the  conditions  incidental  to  at  least  a 
moderate  proportion  of  cases  of  senility,  arteriosclerosis  undoubtedly 
will  be  considered  amenable  to  treatment.  As  to  incipient  senile 
dementia,  the  inference  is  obvious,  and  the  author  believes  this  to 
be  a  very  ])romising  held.  Possibly  certain  types  of  ])rostatovesical 
disease  and  chronic  rheumatoid  affections  of  the  joints  also  may 
])rove  amenable  to  treatment. 

The  thought  occurs  to  the  atithor  that  the  sex  gland  hormone 
possibl}'  nu'ght  increase  the  resistance  of  the  brain  cells  to  toxins 
and  improve  their  nutrition  sufhcientl}'  to  correct  the  ttnderlying 
neuropath}'  of  epilepsy. 

X^eurasthenia.  in  the  author's  opinion,  more  often  is  a  pttrely 
sexual  phenomenon  than  generallv  is  sttspected.  It  seeminglv  is 
due  to  causes  which,  directly  or  indirectly,  affect  the  production  or 
composition  of  sex  gland  hormone.  Long  continued  emotions  of  all 
kinds,  especially  sex  emotion,  ]:)rodtice  it.  \\'orry,  cerebral  over- 
strain, sexual  desire  without  gratification  —  sometimes  even  sexual 
life  withotit  desire  —  sexual  excess,  frecjuent  child  bearing  —  or  no 
children  at  all,  after  the  proper  age  —  irritation  of  the  sexual  appa- 
rattis,  innutrition  from  any  cause,  all  are  disastrotts.  ])robably 
through  vitiating  the  quality  or  lessening  the  quantity  of  the 
hornu.ine  wliich.  in  the  sex  gland  nutriti\'e  cycle,  is  necessary  to  the 
structure  and  functioning  of  both  the  internal  secretory  and  genera- 
ti\-e  secretory  gland  cells  themselves.  Chronic  infectious  diseases, 
such  as  s_\])hilis.  may  be  assumed  to  act  upon  hormone  ])roduction 
in  tw(j  ways,  \\/..:  1.  Worry,  ])r()(lucing  nutritive  depression  and 
])erverte(l  chemism  ;  2.  intoxication  —  inhibition  :ui(l  ]ierversion  of 
t unction  f)f  the  internal  secretor\-  ai)])aratus.  The  result  is  ]m-o- 
loiuul  neurasthenia.  Tlie  exhaustion  ])roduced  b\-  anv  disease  is 
merely   neurasthenia.   ])robabl}'  ])ro(luced  1)\    internal   secretorx'   dis- 


I.MPOTKNCK   AND    STERILITY 

turbancc  affecting  the  production  of  hormone,  the  natural  rejuvc- 
nator  of  nerve  energy.  Possibly  so  called  ])hysical  exhaustion  is 
due  to  the  same  cause,  and  not  altogether  to  "fatigue"  toxins. 

]\Iay  we  not  believe  that  all  the  vital  functions  really  are  mani- 
festations of  hormone  activity,  acting  upon  neuron,  ganglion,  and 
nerve  fibre?  Other  hormones  are  essential,  but  is  it  too  much  to 
say  that  the  sex  hormone  is  most  important  of  all ;  in  brief,  the 
most  potent  link  of  the  endocrine  cvcle  ? 

It  is  probable  that  a  hormone  complementary  to  the  testicular 
hormone  is  produced  by  the  prostate.  The  markedly  beneficial 
results  of  prostatic  massage  in  sexual  neurasthenia  might  be  ex- 
])lained  by.  first,  reflex  stimulation  of  sex  gland  activity;  second, 
liberation  and  aljsori)tion  of  sex  hormone  by  mechanical  pressure ; 
lliird,  the  stimulant  and  tonic  eff'ect  of  the  hormone  on  the  nervous 
s\'stem. 

The  administration  of  sex  gland  hormone  via  implantation  pos- 
sibly may  prove  serviceable  in  malignant  disease.  It  certainly  is 
worth  trial.  The  germ  theory  of  the  etiology  of  carcinoma  has 
not  seemed  to  the  author  well  grounded,  indeed,  he  is  of  o])inion 
that  the  nearer  we  come  U)  a  ])erfect  knowledge  of  the  internal 
secretions,  the  nearer  we  shall  be  to  the  true  etiology  and  rational 
therapeutics  of  carcinoma.  In  an}'  event,  wh;itever  the  aljuormal 
impulse  may  be,  the  result  is  ])erverted  cell  growth,  and  we  may 
at  least  regard  hopefully  any  remedial  measure  that  ])roniises 
improvement  in  cell  nutrition. 

To  ])ut  tlie  author's  view  of  the  etiology  of  malignant  disease 
concretely,  he  believes  that  there  is  more  than  a  chronologic  coinci- 
dence in  the  association  of  sarcoma  with  childhood  and  youth,  and  of 
carcinoma  with  later  life.  A  disturbance  of  cell  nutritive  equi- 
librium from  perverted  cpiantity  or  ([ualitv  —  or  ])()th  —  of  internal 
secretion — probably  of  the  sex  gland,  the  thyroid  ])erhaps  ])laying 
an  im])ortant  ])art  —  in  mv  o])inion  underlies  both  varieties  of 
malignant  disease.  The  sex  gland  hormone  theoretically  should 
restore  this  ecpiilibrium,  making  in  effect  the  cells  of  the  sarcoma 
older  and  stronger  and  those  of  the  true  carcinomata  younger  and 
stronger.  In  the  light  of  the  foregoing  view  of  malignant  disease, 
the  theory  of  C'olmheim  is  csi)eciallv  a])t  in  its  ai)])lication  to  ma- 
lignant disease  of  earlv  life,  and  to  sarcoma  and  the  other  varieties 
of  carcinoma  at   any  age. 

-  2.i6     - 


SEX    GI.AXD    IMIT.AXTATIOX 

'Jlic  association  of  cancer  witli  the  ai)])roach  or  occurrence  cjf 
the  nieno])ause.  and  witli  advancin.i^"  age  in  the  male,  is  sui^gestivc 
of  change  in  the  sex  ghuid  hormone  as  the  cliief  underlying  factor, 
I^pithelioma  of  the  skin,  especially,  may  be  compared  to  psoriasis,  in 
that  a  defect  of  nutrition  due  to  ])erversi(jn  of  internal  secretion  and 
localized  by  special  factors  of  irritation  is  a  reasonable  underlying 
cause. 

'i'he  role  of  micro-organisms  in  carcinoma  ma\-  eventually 
I)rove  to  be  merelv  that  of  a  special  determining  factor  of  perverted 
cell  growth  through  the  irritation  ])roduced.  and  ncj  more  "specific" 
than  traumatism,  which  so  often  a])pears  to  be  the  ])oint  of  de-- 
])artttre  for  malignant  disease. 

'rh_\-roid  extract  has  been  stated  to  have  cured  psoriasis.  This 
is  not  stir])rising.  The  thvroid  and  sex  gland  hormones  seemingly 
are  complementar}-.  Thxroid  defect  ])ossibly  may  be  the  more  im- 
portant factor  in  malignant  diseases  of  early  life. 

Diseases  dtie  to  defective  (jtiantity  and  (juality  of  either,  or  of 
both  hormones.  ])erhaps  ma}'  be  cured  by  either,  bttt  possibly  may 
reqtiire  a  c()m1)ination  of  both.  The  one  thing  needful  in  thyroid 
implantation  may  be  a  simultaneous  sex  gland  implantation.  It  is 
the  author's  firm  conviction  that  the  administration  of  sex  gland  hor- 
mone l)y  implantatinn — with  or  without  thyroid  hormone,  as  events 
ma\-  ])ro\"e — is  well  wortln-  of  trial  in  malignant  disease.  As  to 
whether  beneficial  results  will  follow  organotherai)y.  this  naturally 
will  be  determined  bv  factors  independent  of  the  etiology  of  the 
disease. 

Cask  1\'.  Dementia  praccox,  catatonic  type.  Woman  atied  twenty-six 
\'ears.  family  histdry  unknown.  dvn"ation  of  disease  ])robably  more  than  six 
years  ;  \\'a>sermann  negative.  Operation.  March  8,  1914.  Site  of  implanta- 
tion, deep  within  tlie  ])elvis  in  the  properitoneal  space  on  the  right  side. 
Incision  about  1.2.T  inch  long,  just  internal  to  and  slightly  below  the  anterior 
superior  spine  of  the  ilium.  Alaterial  used,  portion  of  an  ovar\-  removed 
from  woman  of  twenty- four  years  during  a  tumor  operation,  and  refrigerated 
for  thirty  liours.  It  should  be  noted  that  a  gland  removed  from  a  living 
sul)ject  and  refrigerated  is  e(iuivalent  to  one  removed  from  a  dead  stibject 
at  a  corresijonding  ])eriod  after  death — prior  to  beginning  decomposition — 
save  where  the  donor  died  oi  an  infectious  or  an  exhausting  disease. 

The  wound  healed  Ity  pirimary  imion.  Xo  rise  of  temperature.  The 
case  was  examinetl  on  ]\[arch  22.  1914,  The  implantation  appeared  to  be 
success lul.  The  mental  status  was  unchanged.  At  the  second  examination. 
May   11.    l'U4,   the   im])lanted  gland   appareiuly   was   still   /);   .'situ.     There  had 


TAJPOTENCl-:    AND    STJ^RILITY 

been  no  iniprovenieiit  in  the  menial  or  i)hysical  status.  The  author  examined 
the  case.  July  26,  1914.  The  implantation  /ry-  sc  probably  was  a  success, 
although  on  account  of  its  position  the  gland  could  not  be  palpated.  The 
mental  status  still  was  absolutely  unchanged.  ]\ven  granting  the  potency  of 
the  method,  under  favorable  conditions,  a  negative  result  should  not  be 
surprising  in  such  unpromising  cases  as  1  \'  and  \',  or  in  such  as  subseciuently 
were  experimented  upon. 

C.\SK  v.  Poiiciitia  praccox.  (jirl,  aged  seventeen  years.  Duration  of 
disease,  about  three  years  Pro])ably  a  masturbatory  habit.  No  family 
history.  Wassermann  negative.  Operation,  March  8,  1914.  Site  of  im- 
plantation, right  labium  majus.  Alaterial  used,  the  com])anion  to  the  ovary 
implanted  in  Case  II.  This  had  been  merely  refrigerated,  but  not  frozen, 
for  a  week  in  normal  salt  solution.  A  Graafian  follicle  had  just  ruptured 
at  the  time  of  death  of  donor,  and  the  corjjus  luteum  was  beginning  to  form. 
Examination,  Alarch  22,  1914,  showed  that  this  implantation  probably  was 
a  success.  There  had  been  a  slight  rise  of  temperature,  owing  probably  to 
coincidental  incision  of  redundant  labia  and  slight  resultant  infection.  The 
wound  healed  by  ])rimary  iniion,  but  a  small,  apparently  superficial  al)scess 
formed  near  the  implantation  site  bed.  This  was  opened  and  drained.  The 
o\'ary  still  was  ;';;  situ.  .May  11.  1914,  the  oxary  still  was  in  situ.  There 
seemed  to  be  a  slight  im])ro\ement  in  both  the  physical  and  mental  status. 

.■\t  the  last  examination,  July  26,  1914,  the  im])lanted  gland  tissue  was 
barely  discernible  on  ])alpation.  The  mental  condition  was  found  to  he 
remarkabl\'  improved.  There  a])peared  also  to  be  considerable  improvement 
in  the  patient's  jjhysical  condition.  ySo  marked  was  the  improvement  in  this 
case,  that  a  reasonable  number  of  such  apparent  results  justly  could  be 
regarded  as  ])ro]):d)ly  confirmatory  of  the  theory  upon  wliich  the  implantation 
was  based. 

Front  what  is  known  today  of  the  internal  testicular  secretion 
and  of  the  influence  of  the  ovarian  internal  secretions  it])on 
secondary  sex  characteristics  and  the  functions  of  the  nervous  sys- 
tem, especial!}-  in  the  light  of  Fattser's  hlood  dia<>iiostic  ohservations, 
the  internal  secretion  of  the  ovary  seems  to  he  logically  indicated, 
not  onlv  in  earlv  cases  of  dementia  pra'cox  and  allied  conditions  in 
the  female,  htit  es])ecially  in  certain  severe  cases  of  hysteria,  the 
nerve  wreckage  that  often  follows  com])lete  sttrgical  removal  of 
the  o\aries,  in  severe  and  ohstinate  cases  of  neurasthenia,  and  the 
netiro])athy  of  the  nieno])atise. 

Will  such  henelicial  efTects  as  nia\-  he  secttred  hy  a  more  or 
less  continuous  dose  of  internal  secretion  incidental  to  sttccesstul 
sex  gland  implantation  I)e  ])ennanent,  /'.  <'.,  will  the  result  he  mcrel\- 
temporary  stimulation  rather  than  what  ma_\-  he  termed  "regenera- 
tion ?'" 

^-  258  — 


Sl'.X    CI.WI)    I.MI'I.AXTATIOX 

()l)viousl\",  niaU'rial  from  the  li\iii.L:'  sul)ic'Cl  with  iniiiie(hatc' 
transference  from  donor  to  reci])ient  is  tlie  mo>t  (lesiral)le  method 
when  availal)le  —  as  it  rarel_\-  is,  the  effects,  liowever,  will  be  no 
better. 

C'asi-   \'I.     This,  in  a  sense,  is  tlie  most  reniarkahle  ui  all  oui"  inii)lania- 
tion  cases.     Woman,  ni^vd  sixty  years,  senile  dement.     At  tlie  time  of  the  im- 


I'ii^.  1. — Slio\\'ing  jjostei'ior  l)or(ler  of  imphmted  testis,  with  site 
of  removal  of  epididymis,  (A)  and  extensive  vascular  areas. 
(Case  VI.) 


j)lantation  she  apparently  was  in  good  healtli,  save  as  to  her  mental  condition. 
Wassermann  ne.gative.  With  thi'  douhle  ohiect  of  the  p(^ssi1)le  l)eneticial 
etTecl  of  the  male  se.x  hormone  in  senile  dementia  in  the  female,  and  deter- 
miniiiL;'  whether  sex  tilands  coiiUl  ])e  successfully  transplanted  for  therapeutic 
purposes  from  the  one  sex  to  the  other  in  the  human  hein.ii'.  we  made  a  cross 
implantation  in  this  case,  Alarch  18,  1914.  in  this  case  the  possihle  effects 
in  tieneral  of  the  te>ticidar  hormone  on  the  secondary  female  sex  characteristics 
coidd  he  ahsolutely  iiiiiored.  The  gland  emi)loyed  was  the  right  testis  of  an 
apparently  health)  man,  .aged  thirty  years,  dead  from  contact  with  a  live  wire 
The  donor  had  ])een  dead  ten  hours  when  tlie  testis  was  removed.  The 
gland  had  hcen   refrigerated   for   four  days. 

—  2.S9  — 


lAll'OTl'.NCI':    AX  I)    STl'.RIT/ITY 

Till'  gland  wa:-  carefully  prciiarcd  l)y  rcniuxing  the  epididymis  and  slight- 
ly denuding  the  tuhuli  hy  excising  four  longitudinal  strips  of  tunica  albiii^inca 
about  three  mm.  in  width,  extending  lor  the  whole  length  of  the  gland.  The 
entire  gland  was  used.  A  transverse  incision  about  1.25  inch  in  length  was 
made,  about  four  inches  above  the  symphysis  pubis,  down  to  the  aponeurosis 
of  the  recti.  The  wound  was  pocketed  downward  for  approximately  two 
inches,  and  the  testis  implanted  at  the  bottom  of  the  pocket.  The  fascial 
opening  was  closed  with  a  ])ursestring  suture  of  tine  catgut,  the  skin  wound 
with  a  catgut  continuous  suture,  and  the  line  of  closure  settled  with  collodion 
and  gauze. 

Healing    was    prompt,    aseptic,    and    afebrile.       Considerable     swelling 


Fig.    2. — Anterior    border    of    im]>l;inted    testis,    showing    multiple 
vascular  areas.      (Case  VI.) 


develoi)ed  at  the  site  of  the  implantation  and  the  patient  complained  of 
slight  tenderness  on  light  pressure.  The  skin  was  somewhat  reddened  after 
a  few  days,  and  the  implantation  seemed  likely  to  be  a  failure — as  had 
been  exi)ectcd.  ]\luch  to  the  author's  gratification,  however,  su])puration 
did  not  occur,  and  the  case  did  far  better,  so  far  as  the  size  of  the  mass 
which  survived  was  concerned,  than  any  other  of  our  early  testicle  im- 
])lantations.  Alarch  28,  1914,  the  im])lanted  gland  could  be  distinctly  outlined 
on  ])alpation  and  was  fairly  movable.  There  was  no  longer  any  tenderness 
at  the  site  of  im])lantati()n.  May  11,  1914,  the  surrounding  exudate  seemed 
to  have  disapj)eared  and  the  gland  was  circumscribed,  freeh-  movable,  and 
appi'ared  to  be  as  large  as  when  imi)lanted.  July  2(>,  1914,  the  mass  seemed 
considerably,'  smaller   on   ])alpation  ;   it  was  moderate]}'  consistent  to  the   feel, 

—  260  — 


Si:X    C.l.WI)    IMIM.AXTATIOX 


I'i'k'.  ,1. —  l.arcral  view  en'  implant cd  testis  with  minicrdus  \-ascular 
areas.      ( (."asc  W.) 


still    I'rcely    iiKA'ahle,    and    inscnsilix  e.      'i'licrc    had    liccn    no    change    in    the 
physical  or  mental   status. 

]'*or  ])urposcs  of  stnd.w  tlie  in.iplanted  testis  in  the  foregoing  cross 
implantation  was  removed  inider  novocaine.  July  17.  1914.  The  measure- 
ments of  the  excised  mass  were  4  cm.  in  length,  3  cm.  in  lireadth.  and  iimm. 
in  thickness  at  its  thickest  ])art.  The  gland  proper  was  surrounded  hy  a 
pseudocapsule  of  connective  tissue  and  fat.  The  tunica  alhuf/iiica  clcarl}' 
showed,  liere  and  there,  and  contained  numerous  small  blood  vessels.  A'ascu- 
lar  attachments  to  the  surrounding  tissues  were  distinct,  evidentlj'  at  the 
points  of  denudation  of  the  fitiiica  albiKjinca.  The  ])oint  of  severance  of  the 
epidicK^mis    was    flattened    and    showed    a    broad    area    of    vascular    adhesion. 


4.      Lateral  \  iew  of  im]}!anted  te.-^tis  with  mimcrous  va-cular 
areas.      (Case   \'l.  ) 

^  261    — 


njPOTHXCE   AND    STERILITY 


Fig.   5. — Longitudinal    section   of    implanted   testis.      (Case   VI.) 

The  mass  weighed  9.5  grams.  The  proper  capsule  of  the  gland,  the  tunica 
albui/iiica,  and  the  connective  tissue  of  the  mediastinum  showed  beautifully. 
The  substance  of  the  mass,  within  the  tunica  albuijinca,  was  of  a  yellowish 
color,  and  to  the  naked  eye,  distinctly  fatty.  Tlie  macroscopic  and  microscopic 
findings  are  shown  in  the  drawings  ( I'igs.  1  to  12).  Needless  to  saj^  the 
author  was  astonished  to  find  living  tnlnili  scminifcri  and  ducts  in  addition 
to  a  more  than  normally  rich  vascular  sui)ply  and  a  surprising  abundance 
of  interstitial  cells. 

I'Vom  the  results  in  this  case  the  author  concluded  that  im])lanted  human 
sex  glands  from  either  sex  may  survive  in  the  tissues  of  the  opposite  sex, 
there  being  no  greater  tendenc\-  to  necrosis,  and  perhaps  less  rapidity  of 
degeneration  than  in  homosexual  transplantations.  It  is  a  striking  fact  that, 
before  removal,  the  bulk  and  outline  of  the  timior  and  the  conditions  later 
shown  in  the  s])ecimen  were  more  strongly  indicative  of  a  successful  im- 
plantation than  were  the  conditions  in  our  early  homosexual  experiments  in 


I'ig.  0.    -Transverse  sectidu  of  im])]an(e(l  testis.      (Case  YI.) 
—  262  — 


Sl-.X    GLAND    TMPr.ANTATIOX 


'\ii.  7. — 151(>()(1  vessels,  connective  tissne,  and   fat  in  periphery- 
tunica  alhntiinea — of   iini)lante(l  testis.      (Case  VI.) 


b'i>^.  8. — X'unierous  new  blood  vessels,  fat,  and  connective  tissue 
in  and  l)eneath  the  tunica  alhu.uinca  of  implanted  testis. 
(Case  VI.) 


—  263 


1.\1P()TKXC1<:    AND    STKRTIJTY 

citlicr  tlie  male  or  the  female.*  Xo  phj-.siologic  observations  were  made  in  this 
case.  As  already  noted,  no  mental  nor  phj'sical  improvement  followed  the 
imi)lantation  of  the  testis,  but  as  the  subject  suffered  a  fracture  of  the  neck 
of  the  femur  about  ninety  days  after  the  imi)lantation,  it  would  be  difficult 
to  determine  whether  or  not  the  testicle  hormone  was  of  any  value. 

C.\SK  VII.  Man,  aged  fifty-three  j'cars,  musician,  consulted  the  author 
Tune  10,  1914.  Always  a  hard  drinker  and  a  gourmand;  no  history  of 
syphilis;    Wassermann    negative;    history    of    two    tappings    for    ascites,    six 


I'ig.  9. — Showing  area  of  proI)al)l\-  dead,  and  another  of  distinctly 
vitalized  tubuli  seminiferi  with  an  abundance  of  living  inter- 
stitial cells  in  implanted  testis.  The  vitality  (jf  the  glandular 
tissue  and  the  ([uantity  of  interstitial  cells  increases  from  the 
center  toward  the  periphery'  of  the  implanted  gland.  (Case  VI.) 


years  before.  A  diagnosis  of  cirrhosis  of  the  liver  was  made  at  that  time. 
When  the  ]iatient  was  first  seen,  his  alxlomen  was  enormously  distended 
with  fluid.  Jaundice  had  appeared  a  few  da\-s  previously  and  had  become 
(|uite  ])ronounced.  No  pain  was  complained  of,  nor  was  there  any  historj' 
of  ])re\'ious  ])ain.  On  the  scalp,  backs  of  the  arms  and  forearms,  the  elbow^s. 
the  front  of  the  right  leg,  the  buttocks,  and  the  lumbar  region,  were  large 
])atclH's  of  severe,  typic  jjsoriasi^.  from  which  the  patient  h;id  suft'ereel  for 
many  years.  'I'he  p:itclu's  on  the  arms  were  (piite  symmetric,  each  measuring 
about  15  cm.  long  and  9  cm.  wide.     Those  on  the  leg,  six  in  number,  averaged 

*  Tn  exiKM-inu'nts  on  fowl.';,  the  most  dofmitc*  ro.'jult  tlie  author  thus  far 
lias  olitaiiH'd  was  from  an  imi)Uintat  ion  of  a  testis  of  a  yoimj?  cockerel  upon 
a    jinllct    foui'    months    f)l<l. 

-^  264  — 


Sl-.X    CLAXI)    IMI'I.AXTATIOX 

7  cm.  h_\-  4  cm.  The  areas  on  the  >calii  and  hiittock^  were  of  \-ariuus  and 
moderate  .-^ixes.  A  patch  oi"  psoria^i.^  nu-asurinu  7  cm.  hy  9  cm.  existed  on 
the  abflumen.  in\'ulvin,u  a  small  portion  oi  the  skin  co\ering  an  umbilical 
hernia.  'JA\m  ])atches  on  the  lumliar  re.s^ion  mea-nrerl  re-pecti\el_\'  ahont 
6  and  8  cm.  The  subject  was  \-ery  weak  and  markedly-  incommoded  b\'  the 
enormous  bulk  of  his  abdomen.  His  appetite  had  been  excellent  imtil  a  few 
days   before,   since   when    it   had    rapidly    failed. 

June    14th.   the   author   remo\  ed    nearly    ~ix   gallons   of   dark   bile-stained 
transudate    fr(jm    the    abdi,)mina]    ca\ity.    affording    tlie    patient    great    relief. 


I'ig.  Id.-  Section  near  peripberw  al-o  showing  gradual  increase 
of  vitality-  of  gland  tissue  from  the  center  toward  the  peri- 
jiliery  iif  implanted  tt'-ti-.  (Large  am^'unt  >■(  interstitial 
ti-sue. )      (  Ca-e   \'  1.  ) 


The  liver  was  now  found  to  be  greatl\'  enlarged  and  indurated,  showing 
plainly  through  the  collapsed  abdominal  wall.  The  gall  bladder  was  greatly 
distendefl  and  its  walls  thickened  and  hard.  In  the  left  iliohypochondriac 
region  was  a  hard,  oblong  mass  extending  downward  from  the  under  surface 
of  the  li\'er  for  alxnit  four  inches.  I'rom  its  location  this  ttuiior  might  have 
been  either  renal  or  (jmental.  It  couUl  not  be  defmitely  determined  that  it 
was  attached  to  the  liver.  Several  hard,  irregular  masses  were  noted  at  the 
left  (jf  the  median  line  in  the  umbilical  region.  There  was  a  good  sized 
umbilical  hernia,  e\'iflently  now  containing  oidy  fluid,  which  freely  flowed 
back  and  forth  under  pressure.  This  had  been  unsuccessfulh'  operated  upon 
some  }'ears  ago.  The  indue  contained  bile  in  large  amount  and  a  small 
(piantity    of    all)iuuin.    but    no    casts.      The    patient's    heart    was    very    weak 

—  265  ~- 


iMPoTicxci-:  AX  I)  sti-:kility 

following   the   operation    and   strvclmine   was    i;iven   hypodermically    for    sev- 
eral days. 

l{nconraged  by  the  observations  wliieh  already  had  been  made  oi  the 
ai)parent  effects  of  the  sex  hormone  ni)on  nutrition,  and  especially  upon 
that  of  the  skin,  and  with  a  clear  understanding  on  the  ])art  of  the  patient 
of  the  experimental  nature  of  the  i)rocedurc,  the  author  resolved  to  make 
a  testicle  implantation  in  this  case.  On  June  19th,  we  planted  in  the  patient's 
right  scrotal  sac  a  testicle,  with  the  epididymis  excised,  removed  from  an 
ajjparently  healthy  sul)ject  about  twent^'-one  years  of  age,  dead  about  thirty 
hours   before    from   contact   witli   a  live   wire.     Ice  had  been  packed   around 


Fig.    11. — Free    and    attached    interstitial    cells    with    contiguous 
tul)uli  seminiferi  in  inii)lanted  lesti:-.     (Case  A'l.) 


the  testes  for  jierliaps  four  hours.  The  operation  was  done  ten  hours  after 
the  renio\al  of  the  testis  from  the  dead  subject,  /.  ('.,  forty  hours  after  death 
of  the  donor.  The  local  postoperative  course  was  vmeventful  for  two  weeks. 
The  wound  apparently  healed  by  ])rimar3'  union  and  there  was  very  little 
swelling  about  the  site  of  the  imjjlantation.  Until  the  fourteenth  da\-  the 
implantation  jwr  sc  seemed  to  have  been  successful. 

On  the  third  day  after  the  implantation  improvement  was  noted  in  the 
skin  erui)tion.  l!y  the  eighth  day  after  operation,  the  lesions  were  so  im- 
])roved  that  they  scarceh'  could  be  recognized  as  i)soriasis.  The  skin  of  the 
leit  arm  was  nearly  normal.  The  i)atches  upon  the  back  and  scalp  had 
entirely  disappeared.  The  jaundice  had  improved,  the  blood  i)ressure,  which 
was  low  on  account  of  the  patient's  debilitated  condition,  had  increased,  the 
pulse  was  ])erce])til)ly  stronger.  ai)i)etite  greatly  increased,  the  hemoglobin, 
Avhich    was    a])proximately    sixty   per   cent.,    was    now   seventy   ])er   cent.,    and 

—  266  — 


SEX    GLAXD   l.M PLANT ATIOX 

there  was  a  distinct  iniprovemeiit  in  color  of  llie  skin,  aside  from  the  lessen- 
ing of  the  jaundice.  A  considerahle  reaccumuhition  of  fluid  already  had 
occurred. 

The  white  cor])U-<clc  count  sliowed  over  13.01)1)  at  the  time  of  operation. 
On  the  sec(jiul  day  the  wliite  count  wa>  over  21. ()()().  falling  rapidly  after  the 
third  day  to  about  what  it  was  originally.  The  ol)vious  explanation  of  the 
ra]>id  rise  and  fall  in  the  white  cell  count  was  an  ephemeral  reaction  to  a 
foreign  body.  There  wa-  at  no  time  any  noticeable  effect  on  the  sexual 
function,  which   had  been   in   abcwancc    for   several   \'ears. 


]''i,g.  12. —  Section  from  area  of  peri])hery  of  implanted  testis,  cor- 
responding with  site  of  the  epididymis,  showing  vein  contain- 
ing blood  and  vasa  effereiitia.     (Case  \'l.) 
There  were  no  areas  of  softening  or  of  fatty  degeneration  in  the 
interior  of  the  gland.  The  Sertoli  cells  could  not  be  distinguished. 


The  blood  and  skin  conditions  continued  to  improve  and  the  patient 
grew  stronger — de.-])ite  an  cxten.^ive  reaccumulation  of  fluid  in  the  peritoneal 
cavit\- — until  the  fourteenth  day.  The  ])ercentage  of  hemoglobin  had  rapidly 
increased  to  90.  anrl  llie  red  corpuscles,  which  showed  2.27?S)i)i)  at  the  time 
of  the  im])lantation.  liad  increased  liy  the  tenth  day  to  .^6()().l)()().  varying 
from  day  to  day.  but  at  no  time  falling  ])elow  4. 001). 000  before  the  close  of 
the   ca-~e. 

The  --ill.-  of  ibe  p:-oria>i-  on  ihc  left  ai'ui  and  buttock>  now  had  become 
jiracticallv  normal,  and  that  on  the  right  arm  and  leg  nearly  >o.  The  patient 
a^-ertei[  that  hi^  teetli.  whicli  bad  liei-n  so  tender  :'.n<l  I'^ov  tliat  he  could  not 
chew  solirl  f(.iod.  had  ])ecome  so  improved  that  he  could  chew  with  comfort. 

—  267  — 


IMPOTKNCK   AND    STERILITY 

The  scrotal  wound,  wliich  a])])arciitly  liad  united.  reo])ened  superficially 
for  about  half  an  inch  on  the  ninth  day  after  operation.  This  was  apparently 
due  to  mechanic  disturbance,  tlie  enormously  pendulous  abdomen  giving 
rise  to  great  inconvenience.  The  slight  skin  lesion,  while  indolent,  as  was 
to  have  been  expected,  presented  no  evidence  of  anything  but  the  most 
superficial  and  simple  pus  infection.  The  fascial  wound  had  not  reopened 
and  appeared  to  be  soundly  healed.  The  temperature  was  normal  until  the 
fifth  day,  when  it  rose  to  100°  F.  It  fell  to  normal  within  twenty-four  hours. 
On  the  thirteentiT  day  it  again  rose  to  101°  F.,  but  by  evening  fell  to  normal 
and  remained  practically  normal   until  the  close  of   the  case. 

June  30th.  the  author  again  tap])ed  the  abdomen,  removing  fulK'  six 
gallons  of  fluid.  The  testis  still  was  /;;  situ  and  a])])arently  "doing  well." 
The  fluid,  which  at  the  previous  tapping  had  been  clear  and  about  the  color 
of  moderately  strong  coffee,  ikjw  approximated  the  color  of  normal  urine 
and  was  distinctly  turbid.  The  liver  was  perceptibly  smaller  and  the  abdom- 
inal tumors  ])reviously  described  had  markedh*  decreased  in  size  since  the 
first  ta])ping.  Dr.  M.  M.  I'ortis  saw  the  case  and  agreed  that  it  ])robably 
was  carcinoma.  Dr.  Portis  subsequently  examined  the  fluid  and  stated  that 
while  tlie  findings  were  atypic,  he  still  thought  the  case  prolialdy  was  malig- 
nant. The  report  of  tlie  examination  of  the  fluid  withdrawn  at  the  tapping 
was  as  follows  : 

Specific  gravity.  1010;  large  number  of  lymphocytes,  endothelial  cells 
and  embryonal  cells  :  bile  in  moderate  (juantit}'. 

The  shock  of  the  second  ta])ping  was  very  severe  and  the  patient  rapidly 
failed.  On  the  following  day  he  began  to  have  involuntarj'  bowel  and  bladder 
evacuations.  The  slight  granulating  scrotal  wound  became  infected  about 
the  fifteenth  day  after  the  operation  and  on  the  seventeenth  day  pus  was 
distinctly  perceptible  around  the  site  of  the  implantation.  This  was  evacuated 
and  the  implanted  testis  was  found  to  have  been  dissected  out  cleanly  by 
the  ])us,  which  was  distinctlj-  saproi)hytic.  The  gland  was  of  normal  con- 
sistence and  form,  anrl  on  section  the  tubuli  ajjparenth'  were  not  softened  or 
in  the  least  broken  down.  Xo  evidences  of  adhesions  were  perceptible  on 
the  surface  of  the  gland.  The  ])atient  liccame  delirious  and  refused  ali- 
mentation ;  marked  albuminuria  develo])ed.  and  death  from  exiiaustion 
occurred  July  12,   1914. 

The  autopsy  showed  a  greatl\'  enlarged,  but  otherwise  typically  cirrhotic 
liver.  The  omentum  throughout  was  cirrhosed  and  enormously  thickened. 
The  fatty  ca])sules  of  the  kidneys  were  greatly  thickened  and  indurated. 
So  great  was  the  induration  and  thickening  or  the  fatt\'  environments  of  tlie 
alxlominal  organs  tliat  they  were  \vilh  difficulty  removed  for  insijcction. 
The  masses  which  had  sinnilated  malignant  omental  metastases  had  become 
so  reduced  in  size  that  they  wei"e  scarci'ly  |!ercei)tible  before  opening  the 
abdomen.  ( )n  ex]>osiu"e  to  ins|ieclion  tbex'  pro\ed  to  ])v  merely  thickened 
and  liarden.'d  |)ortions  of  omentum.  The  spleen  and  i>anci'eas  were  i.'irrliosed. 
The  kidnt'vs  slinwed  niarl<t'd  inter>titia1  nephritis.  'I'he  author  does  not  recall 
i'\HT  having  met    with  a  case  with  such   e\tensi\e  alcoholic  pathology.     There 

---    2()H   ~- 


SJ'.X    CJ.AXI)    IMiM.AXTATIOX 

\sri>  111)  c\i<kiuc  of  inali,mi;inc\'.  Hi>iiil()t^ic  cxaminatinn  oi  the  li\er  sliowcd 
tyi)ic  cirrho-ii-;.  The  iniplaiiled  testis  was  carelessl_\-  j)reser\'e(I.  and  wlien 
>uhniitted  for  hi>tul(),L;ic  >tiid\-  \va>  fmiiid  ti:i  l)e  so  decmnposed  as  to  l)e 
wortldess   for  stud_\'. 

'Idle  lore.yoiny  case  was  a  se\ere  test  of  sex  .yland  implantation  and  tlie 
apparent  results  upon  the  hlood  and  >kin  were  correspondint;ly  noteworthy. 
A-  a  i)rohal)le  index  to  the  i)hysiolo,L;ic  effei'ts  (.)f  the  sex  hormone,  the 
ehaiiKes  iii  the  ])soriatic  skin  were  phenomenal.  That  the  subject  received 
the  heiietit  of  hoth  the  initial  and  the  >econdary  ])!iy<iolofi-ic  ctYects  of  the 
hormone  is  prohalile.  The  author  l)e!ieve->  that  tlu'  testicle  elaborated  hormone 
until  the  >crotal  infection  occurred.  ;>  period  of  two  weeks.  That  any  remedy 
what-oe\er  could  ett'ect  such  niarkefl  changes  in  the  C(.indition  ot  the  blood 
and  >kin  in  so  unpromising  a  ca>e  as  the  fore.uoin.e.  is  remarkable.  Xo  treat- 
ment (jlher  than  ini]dantation,  •^a\■e  attention  to  the  bowels,  was  i>'iven.  The 
changes  hardly  could  have  been  ^jjontaneous  in  a  ca>e  in  which  there  existed 
no  natural  tendency  to  improvement.  The  survival  of  the  im])lanted  testis 
for  so  loiiK  a  periocl  in  a  subject  in  which  the  nutrition  of  the  tissues  of  the 
donor  was  so  impaired  is  in  itself  ])henomenal.  The  a])parent  improvement 
in  the  biliar\'  obstruction,  aiul  the  diminution  in  size  of  the  li\'er  and  omental 
masses  arc  merely  ncjted  as  clinical  phenomena,  with  no  suggestion  of  any 
pirobable  relation  to  them  of  the  sex  hormone.  'Jdiey  obviously  are  susceptible 
of  other  explanations,  which  harflly  can  be  true  of  the  skin  and  blood 
phenomena. 

'J'lie  action  and  interaction  of  the  ini])]antc'(l  \-oun,2;  "-land  and 
its  senile,  or  even  niiddle-a_n'ed  environnient,  are  worthy  of  seriotts 
cemsidcration.  'I'o  what  extent  an  a^q'ed  environnient  of  nerve  inflti- 
ence  and  tissue  juices  eventually  will  alter  the  l)iochcniisiu  of  the 
iiu])lanted  ,^-land  intist  remain  an  o])en  f[ttesti(Mi.  Stihse(|ttent  experi- 
ence has  seemed  tfj  show  that,  while  the  inland  atro])hies  perha])s  a 
little  faster  than  in  }-oun.y"er  soil,  its  life  is  iirolont^ed  sttfficientlv  to 
>ecure  marked  action  of  the  hormone- 

That  the  imjjjanted  inland  wi'!  henetit  more  or  less  1)\-  the  im- 
])roved  fjualit}'  of  the  hlood  ])rodttced  h}'  its  own  internal  secretion 
seem>  lo.q-ical  eiuni.^'h.  To  what  extent  anrl  for  how  lon,^^  a  time  is 
])rol)leniatic. 

The  inte,<4rit\-  of  tlie  ^'land  ti>~~tie  and  the  qualitv  and  ([tiantity 
(.f  its  ])ro(hict  ol)\-i()U>]\'  are  laro'eK'  dominated  1)\'  the  elements  on 
which  it  fecfls.  Imidanted  \oun,i^-  ^land  tisstie  ])ossil)ly  may  not 
lon^'  remain  \'otm,<^'  when  fed  on]\-  1)\"  the  l)]ood  of  more  mattire, 
and  c-^ijecialh'  of  -^cnile  life.  l'"ac]i  ^ex  inland  is  a  lahoratory  :  the 
^'land  cells  are  the  worker>.  These  workers  select  from  the  hlood 
ihe  materials  for  the  elahoraiion  of  hoth  the  iniernal  and  procreative 


269 


lAFPOTENCE   AND    STERILITY 

secretions.  C])()n  the  (|uality  and  quantity  of  these  materials  depend 
the  quahty  and  (juantity  of  the  finished  product. 

'^I'he  end  result  of  implantation,  therefore,  possibly  may  be 
merely  the  elaboration  and  absor]:)tion  into  the  blood  of  a  larger 
quantity  of  internal  testicular  or  ovarian  secretion  than  the  reci])i- 
ent's  own  glands  are  capable  of  ])roducing,  this  secretion  eventually 
becoming  of  the  same  ([uality  as  the  subject's  own  secretion,  in 
this  event  the  benehts  derived  from  iiuplantation  w'ould  be  only 
such  as  would  result  from  a  constant  dose  of  a  larger  quantity  of 
internal  secretion,  of  a  ])otency  identical  with  that  produced  by 
the  reci])ient's  own  glands.  If  it  should  i)rove  to  be  true  that  a 
gland  im])lanted  in  an  elderly  subject  becomes  greatly  moditied  by 
its  new  environment  —  which  modification  should  not  be  astonish- 
ing, for  "the  cell  is  what  it  eats"  —  then  the  same  consideration 
would  even  more  forcibly  a])ply  to  a  gland  taken  from  an  elderly 
donor  and  implanted  in  a  younger  recipient.  The  nutrition  of  an 
old,  but  still  functioning  gland  probably  is  more  likely  to  be  im- 
proved by  young  blood  than  a  young  gland  is  to  be  deteriorated 
by  old  blood.  This  suggests  more  leeway  in  procuring  material. 
It  eventtially  may  be  shown  that  there  are  s]:)ecial  indications  for 
the  selection  of  a  gland  from  a  donor  of  relatively  advanced  age  as 
best  ada])ted  to  the  condition  in  hand. 

Mow  far  the  trophic  influence  of  the  relatively  aged  nerve 
supply  of  the  implantation  site  may  affect  the  permanence  of  im- 
plantation results  would  Ije  difficult  of  conjecture.  It  is  hardl}' 
])nssible  that  a  comnuinitv  of  nerve  supply,  sensory  or  tro])hic.  or 
both,  could  l)e  estaljlished  l)etween  the  im])lanted  gland  and  the 
investing"  tissues.'"  If.  however,  we  ever  succeed  in  greatly  im- 
peding the  wheel  of  time  in  its  remorseless  grind  upon  human 
life  —  and  the  author  is  willing  to  confess  optimism  —  it  is  most 
likel}-  to  be  through  the  agenc\-  of  internal  secretion  thera])y,  via 
gland  implantation.  As  to  what  glands,  or  combinations  of  glands, 
will   ])rove  most   efficacious,  the   futtux  alone  can   show.     The  sex 


*  The  ri-siilts  nf  ini pbi  lUa t ii jii  in  several  of  oui-  cases  ai'e  iiiteresUns-  and 
iin]iorlaiit  in  their  relaliims  (ci  the  elTin-ts  of  fatal  eleclrieal  shock  on  cell  vitalits' 
in  general,  and  possihlN  nia\  lia\e  a  lu'arinL;  upon  the  ]>ossiliilit>-  of  resuscitation 
aflei-  siiiipesed  death  Ironi  the  electric  current.  The  author  belie\-es  tliat  ctdl 
\'italit\-  \aries  with  the  dosai^e  ol'  and  duration  of  e.\|iosure  to  the  current. 
l)(iul>tless  in  snnie  eases  the  seX  .ulands  would  not  l),'  suitable  inateiial  for  ini- 
phuit.'i  lion. 

—  270  — 


SI-'.X    ("J.AXI)    lAirr.AXTATIOX 

gland  secretion  seems  to  l)e  the  most  important  of  all  the  internal 
secretions  so  lar  as  its  ]»ossihle  ettects  in  increasing  etViciencN'  and 
lon<4"e\-it_\-  are  concerned.  Indeed,  it  may  be  a  ])o\\erftil  stinnilant 
to  the  activit\'  of  all  the  (jther  hormone  ])r()dticing  orgatis.  In  any 
event,  senilit_\-  and  its  control  are  merely  a  matter  of  ntitrition. 

If  a  complementar}-  hormone  shotild  he  fotmd  to  be  necessary 
to  the  ftill  ])h}siologic  action  ot  the  sex  gland  hormone,  it  mav 
])rove  to  be  the  thyroid,  ])itttitar_\'.  pineal  gland,  or  the  sitprarenal  — 
or  several  of  these  in  combination.  'Jdie  thyroid  swelling  incidental 
to  menstrtiation  and  sexttal  excitation  so  freqtienth'  manifested  in 
cases  of  hyjjerthyroidism  certainly  is  ([tiite  sttggestive.  'J'he  pro- 
fotmd  nntriti\-e  ettects  of  thyroid  internal  secretion  are  familiar 
enongh.  Possibly  the  ettects  oi  the  sex  hormone  (tn  the  thyroid 
i-^  in  a  --ense  "inhibitory."'  rather  than  com])lementary.  the  th\-roid 
running  riot,  so  to  speak,  with  restilting  hyperth\'roidism  when  the 
intittence  of  the  sex  hormone  is  removed.  Granting  this  hypothesis, 
(iraves'  disease  wottld  be  an  indication  for  sex  gland  implantation. 
\\".  Blair  Hell  says,  in  reference  to  correlation  of  the  internal  secre- 
tions in  regard  t(j  their  genital   fttnctions  : 

^^'hen  the  reproductive  functions  cease  and  the  ovaries  atrophy  at  the 
menopause,  tlie  harmony  between  general  and  genital  metabolism  is  tem- 
porarily deranged,  and  various  disturbances  may  ensue.  The  basis  of  treat- 
ment is  the  administration  of  the  necessar}-  secretions.  Some  patients  react 
to  tluToid  extract.  S(jme  t(j  pituitary,  others,  again.  Xo  coml)inations.  so  great 
are  the   indi\'idual  \ariatiiins. 

Strictl\"  speaking,  the  o\'ary  is  concerned  onh'  in  the  temporary  function 
of  reproduction,  and.  by  its  hormones,  of  bending  the  metabolism  of  the  body 
t(;  its  purpose.  As  accessory  to  these  functions  the  ovar\-  has  been  supposed 
to  be  responsible  for  the  beauty  of  the  vessel  by  means  of  which  its  ends 
are  io  be  attained.  I)Ut  toda>"  one  is  beginning  to  w(.)nder  how  far  the  ovary 
does  influence  secondary  sex  characteristics,  and  whether  full  secondary- 
characteristics  can  be  ol)tained  by  the  influence  of  the  ovary  alone.  There 
is  evidence  that  hyi)erplasia  of  the  suprarenal  cortex  can  upset  an\'  influence 
that  the  female  genital  glanrl  ma\"  possess,  and  can  i)roduce  in  a  female  some 
of  the   secondary  characteristics  of  the  male. 

Any  influence  the  ovar}-  has  over  general  metabolism  is,  then,  related 
to  and  dependent  on  its  primary  reproductive  function.  It  probably  does  not 
influence  metabolism  except  in  so  far  as  this  special  function  is  concerned. 
Removal  of  the  ovaries  may  produce  temporary  disturbance,  but  this  does  not 
in\'alidate  the  view  mentioned. 

The  rest  of  the  ductless  gland  system  is  related  to  the  genital  functions 
in    various    ways.      The    thyroid,    pituitary,    and     suprarenals    influence    the 

—  271   — 


].MPf)TliXC]<:    AND    STJ^RIMTY 

development  and  subsequently  preserve  the  integrity  and  activity  of  the 
genitalia.  Others — the  thymus  and  possibly  the  pineal — appear  to  prevent 
sexual  precocity.  All  the  ductless  glands  control  metabolism  in  response  to 
the  necessities  of  the  genital  functions.  In  addition  they  adapt  the  whole 
organism  to  the  possibility  of  the  situation,  and  regulate  the  secondary 
characteristics,  both  ])hysical  and  psjxhical,  to  suit  the  needs  of  the  individual. 
Once,  however,  the  reproductive  organs  are  removed  or  undergo  atrophy,  the 
l)rimary  genital  functions  of  the  rest  of  the  ductless  glands  cease,  and  the 
rearrangement  of  the  metabolism  that  follows  produces  what  are  known  as 
s3'mptoms  of  the  menopause.  Contrariwise,  insufficiency  of  the  thyroid  or 
suprarenals  causes  the  cessation  of  the  genital  fimctions  with  atrophy  of 
the  uterus. 

The  ])()ssil)ility  of  sex  ^'land  ini])lant;iti()n  increasing  lons^'evitv 
reqitlres  special  consideration:  A  sticcessftil  implantation  niay  not 
api)reciably  alter  the  strtictnre  of  the  recii)ient's  tissues  and  organs, 
although  the  effect  on  the  skin  and  blood  ])resstire  of  the  expei"i- 
ment  outlined  in  this  volume  naturally  is  suggestive.  The  viscera 
in  general,  and  es])ecially  the  heart,  l)lood  vessels,  and  the  nerve 
and  brain  tissttes,  may  remain  essentially  the  same,  yet,  even  grant- 
ing this,  further  senile  changes  should  be  retarded  if,  as  seems 
])robable.  the  internal  secretions  of  the  generative  organs  eventually 
are  })roved  ])rofoundly  to  affect  nutrition.  In  l)rief,  we  may  hope 
to  retard  senility  even  if  we  cannot  "citrc"  it. 

The  ((uestion  at  once  sttggests  itself,  .Might  not  the  stimttlating 
effect  of  the  secretion  defeat  its  own  ends  by  exposing  to  overstrain 
organs  —  notabl}-  the  heart  —  alreadx'  senile?  Possibly,  even  prob- 
ably, it  wotild  do  so,  unless  the  increased  efiiciency  was  conserva- 
tively em])loyed.  I^ven  if  an  increased  capacity  for  long  stistained 
and  considerable  nntscttlar  effort  and  increase  in  res]:>iratory 
ca]!acity  should  result,  no  one  who  is  otit  of  training  shotild  expect 
great  tolerance  of  severe  stress  on  heart,  wind,  and  limb. 

It  has  occttrred  to  the  attthor  that  sex  gland  implantation  is 
likely  to  give  the  most  satisfactorx'  resttlts  when  employed  at  or 
abotit  middle  life,  with  the  view  of  retarding  senility  and  preserving 
efiiciency,  or  increasing  it.  if  it  is  below  ])ar.  The  normal  man  of 
forty  xears.  possibl}'.  might  at  least  retaitt  the  vigor  of  forty  years 
until  more  adxanced  age.  The  man  i)ast  middle  age  with  impaired 
efficienc)'  would  be  likel\-  to  hax'e  liis  (.'fficiencN-  restored.  Sttccessive 
im])lantations,  ot  cotu'se,  might  ])r()ve  to  be  necessarw  We  have 
shown    that    ini])lantation    of    the    re])r()dtictive    glands    is    especially 

—  ni  — 


S1-:X    CJ.AXl)    IMIM.AXTATIOX 

effective  in  yonny'  sul)jects  with  (lefecti\e  i)h\sical  sextial  and 
psychosexnal  de\el()])nient.  and  in  stil)iects  who  have  l)een  trau- 
niatically  deprived  ot  the  i;enerati\e  glands — recentlv  in  voung 
subjects,  or  at  any  time  in  sul)jects  ])ast  the  age  of  pnbertv.  In 
connection  lierewith  it  is  well  W  remember  that  the  eti'ect  shoitld 
be  more  marked  in  young  subjects  in  whom  the  chief  secondary 
sex  characteristics  never  have  been  normally  develojjed,  than  in 
older  subjects. 

('.ranting  that  the  method  ])roves  valuable  in  mental  conditions, 
stich  as  dementia  ])r;ecox.  the  degree  of  benefit  and  ])ermanence  of 
results  of   sex  gland  imi)lantation   will   de])en(l   tt])on: 

1.  'J'he  age  of  the  ])atient. 

2.  The  s])ecihcitv  and  acti\-itv  of  sitch  infective  cause  as  mav 
be  determined. 

3.  The  ditration  of  the  disease  and  the  amount  of  secondary 
degenerative  changes. 

4.  'J'he  degree  to  which  perversions  and  defects  of  other  in- 
ternal secretory  glands  enter  into  the  etiology. 

5.  'Jdie  dose  and  activity  of  hormone. 

'J'he  ])robable  efficiency  of  sex  gland  trans])lantation  in  sextial 
perverts  and  inverts,  in  whom  the  normal  ])sychic  or  physical,  or 
both,  sex  characteristics  are  poorl}-  developed,  at  once  suggests  itself. 
Paresis  seems  to  be  a  suitable  lield  for  exi)erimentation  with  sex 
gland  im])lantation.  and  the  author  already  has  operated  in  tw(j 
cases,  in  which,  however,  local  failure  ])revented  aity  possible 
therapeutic  results.  The  third  case  is  tcjo  recent  to  permit  tis  to 
draw  conclusions.  S\philis  in  the  donor  ma}'  here  be  disregarded. 
It  is  an  interesting  qtiestion  whether  many  of  the  mental  vagaries 
and  moral  perversions  that  so  often  develo])  after  middle  age  are 
not  due  to  a  lessening  or  ])erversion,  or  both,  of  internal  sex  gland 
secretion.  \\'e  are  wont  to  attrilntte  these  conditions  to  strtictural 
arterial  changes,  but  the  justice  of  this  is  doubtful.  Future  ex- 
])erience  with  sex  gland  im])lantati()n  seems  to  me  likely  to  change 
our  \iews  in  this  regard.  Indeed,  even  where  arterial  changes  are 
proved,  a  defective  sttpplv  or  vitiated  (|ualit\-  of  hormone  some- 
times mav  be  the  \-er\-  essence  of  the  etiologw  The  mental  al)erra- 
tions  which  so  fre([tientlv  follow  castration  in  either  sex  are  sug- 
gestive in  this  connection. 

—  273  — 


IMPOTENCE   AND    STERILITY 

Tlic  possible  detrimental  action  of  the  secretions  of  the  im- 
planted gland  n]X)n  the  functions  of  the  recipient's  own  glands  has 
in  a  way  been  decided  by  Aletchnikoff's  experiments.  In  1898,  he 
produced  "serums"  from  both  human  and  lower  animal  semen.  He 
killed  the  spermatozoa  in  the  serums  l)y  heat.  When  injected  intra- 
venously, these  serums  destroyed  the  s])ermatozoa  through  the 
medium  of  a  cytotoxemia.  'J'his  toxemia  was  temporary,  the  sperma- 
tozoa finally  acquiring  immunity.  Since  the  ex])eriments  herein 
reported,  examination  of  the  seminal  secretion  in  several  cases 
showed  the  secretion  to  l)e  normal  in  each  instance.  In  one  experi- 
mental case  the  wife  of  the  subject  conceived  a  few  months  after 
the  implantation. 

Obviously,  if  destruction  of  S])ermatozoa  resulted  from  im- 
])lantation  because  of  toxicity  of  a  large  dose  of  alien  secretions, 
the  evil  could  be  only  temporary,  unless  the  anatomic  and  physio- 
logic machinery  of  their  elaboration  was  destroyed,  and  this  would 
involve,  first,  impairment  of  testicular  structure  in  the  recipient ; 
second,  aberration  of  nervous  su])ply  ;  third,  i)erverted  blood  consti- 
tution or,  fourth,  a  combination  of  two  or  more  of  these  conditions. 

In  the  author's  first  paper  in  1914  he  said : 

"Should  sex  gland  implantation  prove  to  be  as  great  an  advan- 
tage in  therai)eutics  as  the  author  is  inclined  to  believe,  we  soon 
will  relegate  certain  gland  extracts  to  the  dead  lumber  room  and 
use  only  the  physiologic  living  extracts,  administering  them  continu- 
ally via  implanted  gland  tissue.  And  who  shall  say  how  far  the 
])rinciple  may  be  ap])]ied  if  tissues  from  dead  l)odies  can  often  be 
successfully  used?  vSex  glands,  thyroid,  liver,  pancreas,  brain, 
s|)leen,  kidney — it  is  impossible  to  say  where  vito-organotherapy 
will  end,  for  it  is  by  no  means  certain  that  all  tissues  have  not  a 
selective  action  on  the  blood,  or  a  s])ecial  biochemic  action,  the  fresh 
])roducts  of  which  are  of  therapeutic  value.  In  brief,  each  tissue 
l)OSsibly  manufactures  its  own  sj^ecial  amnnmition  —  antibodies  — 
with  which  to  combat  disease,  and  even  if  growth  of  the  implanted 
tissues  should  not  occur,  it  is  ])ossible  that  a  sufficient  dose  could 
l)e  given  and  a  stifficiently  prolonged  action  secured,  to  accomplish 
valuable  results.* 


*  In  pas.sing-,  it  is  worthy  of  comment  as  a  medical  curiosity  tliat  tlie 
muc'li  derided  ('al)anis,  in  tlie  latter  part  of  the  eighteenth  century,  asserted 
that  tlie  brain  was  a  seci'etory  organ,  "secreting  thoughts  just  as  tlie  stomacli 
secretes  bile." 

—  274  — 


SEX    GLAXD   LMPr.AXTATIOX 

■"In  the  li.Li'lit  of  AlxIcrlialdenV  wonderful  work,  it  mav  evciit- 
uallv  be  shown  that.  1)_\-  a  special,  selective,  trophic  action,  every 
hiyiih"  s])ecialize(l  tissue  and  ort^an  of  the  body,  whether  glandular 
or  not.  elaljorates  an  internal  nutritive  metabolic  prodtict  —  "secre- 
tion"—  of  its  own.  The  atuhor  wotild  suggest  especially  the  ad- 
visabilit}-  of  ex])eriniental  subcutaneous  administration  of  emulsions 
of  fresh  human  brain  tissue  in  certain  derangements  of  the  brain 
and  nervous  system.  s])lenic  tissue  in  certain  anemias,  heart  tisstte 
in  cardiac  disease,  thyroid  in  h}'poth}'roidism.  kidney  tissue  in  renal 
diseases,  hmg  in  pulmonary  disease,  liver  and  pancreas  in  diabetes 
and  of  sex  glands  in  various  conditions." 

The  author  since  has  experimented  in  this  manner  (in  1914) 
with  emulsions  of  renal  tissue  from  a  recently  dead  human  body,  on 
the  guinea-pig.  and  en  one  human  suljject.  Xo  harm  resulted,  save 
a  transitory  orchitis  in  the  gtiinea-])ig.  As  already  stated,  he  also 
has  experimented  extensivelv  with  htiman  brain  emulsion. 

Possibly  the  hormone  of  the  internal  secretion  of  glands,  or 
certain  metabolic  ])ro(hicts.  elaborated  by  certain  other  tissties.  is 
taken  up  by  the  blood,  returns  to  the  tisstte.  and  stimulates  its  ordi- 
nary vital  functions.  This  "secretion-ntttrition-c\'cle"  —  if  we  may 
be  so  bold  as  to  coin  a  term  —  perha|)S  ma\'  be  necessary  to  the 
normal  life  of  the  tisstte  itself. 

How  far  one  internal  secretion  may  su])plement  another,  is  a 
fascinating  tield  for  s])eculation  that  already  has  received  attention 
in  this  volume.  The  author  is  especially  inclined  to  believe  that,  in 
certain  cases,  the  sex  gland  secretion  may  be  a  powerful  adjtivant 
to  thyroid  or  other  hormone  therapy,  especially  where  simultaneotis 
implantation  of  sex  glands  is  ])erformed.  As  for  extracts  of  glands 
(jf  the  lower  animals,  their  field  oi  usefulness  probably  always 
will  l)e  liiuited.  while  as  for  implantation  of  such  alien  tissues, 
failure  naturallv  should  be  expected.  A  priori  it  would  seem  as 
illogical  as  was  the  old  method  of  transfusion  of  blood  from  the 
lower  animals  —  }et  such  implantations  ])ossibl}'  ma_\'  have  a  certain 
range  of  thera])eutic  usefulness. 

Since  his  fir>t  series  of  experiments  were  made  and  the  greater 
])an  ()\  this  clia])ter  was  written,  the  author's  attention  has  been 
called  to  some  \'ery  interesting  ol)ser\-ations  which,  so  far  as  the\' 
,l:o,  sc-r\e  to  strengthen  the  ])osition  herein  recorded  regarding  the 
\alue  of  sex  gland  trans])lantation  hormone  therapy. 

—  275  — 


IMPOTENCE   AND    STERILITY 

Leopold-Lcvi  reports  a  case  of  rheumatism  and  ])Soriasis,  asso- 
ciated witli  liv])o  thyroidism.  siiccessfullv  treated  with  tlivroid  ex- 
tract. Ill  another  case  of  ])soriasis  excellent  results  followed  the 
administration  of  "testicular  ])()wders." 

(larre.  of  IJonn,  has  expressed  himself  enthusiasticallv  rei;ard- 
inj^-  the  pros])ects  of  thyroid  im])lantation.     He  savs : 

Traiis])laiitati<)n  of  the  thyroid  will  rc\'olutioni/.c  the  work  of  the  social 
worker  within  a  few  years.  Crime,  idiocy,  the  lack  of  develoi)ment  in 
children,  det^eneracy  will  he  lessened  through  the  knowledge  of  this  reniark- 
ahle  organ  which  is  jirst  dawning  upon  ns. 

To  the  tln'roid  ha\e  heen  traced  thousands  u])on  thousands  of  cases 
of  stunted  growth,  o\  mental  imdevelopment.  of  idiocy,  and  sucii  defects. 
An  tmdeveloped  thjToid  means  an  undevelo])ed  child. 

Let  us  take  the  case  of  father  and  son.  The  father  has  a  normal 
thyroid,  and  the  son's  is  undeveloped,  hence  he  is  making  no  progress, 
mentalh'  or  phj-sically.  We  can  remove  one-third  or  even  two-thirds  of  tlie 
father's  gland  without  injuring  him  in  the  least,  and  hy  transplanting  this  to 
the  son  can   soon  hring  him  to  ])ositive  normal   development. 

'rransi)lantation  of  thyroid  from  the  dead  to  the  livinj;-  tmder 
])r()per  conditions  ])rol)ahly  is  qtiite  as  i)racticable  as  transplantation 
from  tlie  livint^"  to  the  liviui^,  unless,  as  Carrel  has  stated  and  Garre 
seems  to  believe,  and  in  a  measiu'e  contrary  to  the  aitthor's  experi- 
ence with  the  testicle,  donor  and  recipient  al)solutelv  must  he  closelv 
related. 

Handler  states  that  he  has  used  ovarian  extract  with  success  in 
dysmenorrhea,  the  disturbances  of  the  climacteric,  atrophy  of  the 
tttertis,  and  amenorrhea.  As  he  tisitally  combines  iron  with  the 
ovarian  extract,  comment  is  unnecessaiw. 

Dubois  and  Roulet  assert  that  intravenous  injections  of  prosta- 
tic extract  produce  a  fall  of  blood  ])ressttre.  with  an  associated 
increase  of  brain  vohtme  and  a  lessening;'  of  renal  tisstie  volume. 

Iscovesco  notes  the  eti'ects  of  a  "li])oid"  extracted  from  the 
testis  and  ovarv.  Clinical  trial  of  this  li])oid  in  the  daily  dose  ot 
0.02  ,<;'ram  (one-third  of  a  grain)  for  thirtv  da\s  in  eleven  jjatients 
stilTcrini^-  from  hypochondria,  or  neurasthenia  with  sexual  weak- 
ness, and  in  ei^ht  a^ed  men.  restilted  in  increased  _i;cneral  \i,^'()r. 
a  better  mental  attitude,  and  im])roved  ca])acit\-  for  work.  In  foiu' 
of  the  eis^L;  old  men  the  blood  ])rc'ssure  was  lowered.  \  esical 
tenesmus,    due    to    ])roslatic    h\])ertro])b\-,    in    three    of    the    cases, 

—  276  — 


SI'.X    (U.AXI)    IMIM.AXTATIOX 

disai)i)eared  c()ni])letc'ly  and  |)cniiancntly  after  an  injection  of  0.1() 
i^Tani  (two  and  a  half  grains)  of  the  li(|uid.  Xo  toxic  eftccts  were 
noted  from  tlie  larj^e  doses,  either  in  these  ])atients  or  in  the  animals. 
The  author  la\s  stress  on  the  er}-throcytic  ])ro])erties  of  the  lipoid 
and  extols  it  in  the  treatment  of  severe  anemia,  notahly  chlorosis, 
and  in  severe  c(jn(litions  of  inntitrition. 

In  additicjn  to  the  implantations  alread}'  recorded  herein, 
the  author.  ])rior  to  the  c()m])letion  of  his  hrst  ])ai)er  (  Aut^itst  1, 
\^)]4).  had  |)erf(jrmed  o])erations  in  hoth  sexes,  itsing  material  that 
had  heen  refrigerated  from  three  to  seven  days.  The  cases  com- 
])rised  two  females  and  ei_^ht  luales.  suffering"  from  various  condi- 
tions, three  senile  dements,  two  cases  of  dementia  ])r;ec()x.  two  of 
epilepsy,  and  three  of  genera!  paresis.  In  two  suhjects  a  douhle  im- 
])]antation  was  made.  In  one  an  anastomosis  of  the  vas  was  ])er- 
formed.  In  one  case,  a  male,  a  cross  im])lantation  was  made.  None 
of  the  suhjects  was  promising,  and  as  all  were  institutional  cases, 
a  discriminating  selection  was  not  ])racticahle.  Full}'  ai)])reciating 
this,  as  well  as  otlier  unfavorahle  environmental  conditions  which 
:i.re  inse])aral)le  from  ex])erimental  work  in  large  ])ul)lic  institutions, 
and  while  hoping  for  l)enehcial  thera])entic  results,  the  attthor  feared 
that  in  all  the  cases  the  ])rincii)al  result  would  likely  he  the  ac([uire- 
ment  of  a  hetter  knowledge  of  the  limitations  of  sex  gland  implanta- 
tions per  se.  and  he  was  onlv  too  glad  to  avail  himself  of  such 
material  and  conditions  as  were  ohtainahle.  The  resttlt  in  the  ma- 
jority of  the  o]jerati(jns  can  be  \'er\-  l)riet]\-  recorded  : 

'Jdie  im])lantations  failed  in  all  of  the  males  and  in  one  of  the 
teiriales,  with  var_\ing  degrees  of  local  infection  and  temperatin-e. 
The  environmental  conditions,  the  had  condition  of  the  subjects. 
and  the  ditiiculty  of  ])re\enting  mentalK'  deranged  suhjects  from 
handling  the  im])lantation  sites,  probal)]}-  had  much  to  do  with  the 
failures,  hut  the  autlior  is  (lis])osed  to  charge  them  cliiellv  to  the 
material  used.  Different  restilts  ])Ossihl_\-  might  have  been  obtained 
it  the  implanted  glands  had  been  ])reserve(l  b\-  com])lete  freezing. 
This,  however,  remains  for  sttbsec[uent  solution.  The  results  ])rob- 
abl_\-  could  not  fairly  be  ascribed  to  the  heterologous  source  of  the 
glands.  In  ])art  of  this  series  of  cases  the  local  conditions  were 
favorable  for  some  davs.* 


Xoto   h-lter    in    X.    Y.    Medical    .Tournal,    >[ar.    2:;,    3  914. 

—  277   — 


IMPOTENCE   AND    STERILITY 

The  case  of  anastomosis  in  an  old  man  of  seventy-five  years,  a 
senile  dement,  was  rather  interesting.  The  implantation  womid 
healed,  the  case  was  afebrile  and  looked  very  promising  for  about 
ten  days,  when  the  gland  and  the  surrounding  inflammatory  area 
began  to  break  down  and  slowly  soften.  On  the  fourteenth  day 
we  opened  up  the  ])urulent  collection  and  removed  the  tunica  olbii- 
giiiea,  which  was  all  that  remained  of  the  implanted  testis.''''  The 
gland  had  been  refrigerated  only  four  days,  and  as  the  companion 
organ  was  still  m  situ,  July  26,  1914,  in  a  female  dement  subject 
(Case  VI)  in  whom  it  was  implanted  on  the  same  day  the  anasto- 
mosis was  performed,  the  material  probably  was  not  at  fault.  Anas- 
tomosis necessarily  is  a  severe  test  of  implantation,  even  under  the 
most  favorable  conditions.  The  donor  of  the  testis  was  a  man  of 
thirty  years,  dead  ten  hours  from  contact  with  a  live  wire. 

In  one  of  the  males  a  double  scrotal  implantation  was  per- 
formed, using  on  one  side  an  ovary  taken  from  a  nuilatto  woman 
dead  eight  hours  of  disease  of  the  heart.  'I'he  testis  was  from  a 
subject  dead  twelve  hours  of  a  skull  fracture  received  two  days 
previously.  The  material  had  been  refrigerated  three  days.  The 
infection  evidently  was  due  to  the  implanted  testicle,  spreading  to 
the  opposite  side  for  when  the  organs  were  removed  from  the  in- 
fected area  on  the  fifth  day,  the  ovary  still  was  normal  and  adhesions 
already  were  noticeable  on  its  surface. 

The  other  ovary  taken  from  the  mulatto  was  cystic.  '^^Phe 
pathologic  tissue  was  excised  and  a  small  ovary  reconstructed  from 
the  apparently  normal  glandular  remnant,  enveloped  in  an  ad- 
herent fragment  of  broad  ligament,  and  im])lanted,  March  18,  1914, 
in  the  axilla  of  a  female  senile  dement,  sixty-seven  years  of  age. 
The  wound  healed  aseptically  without  any  rise  in  temperature. 
!May  11,  1914,  the  gland  a])parentl_v  still  was  in  situ.  On  July  26, 
1914,  a  small  movable  body,  a  little  larger  than  a  good  sized  pea, 
still  could  l)e  felt  at  the  site  of  the  implantation.  As  there  was  very 
little  gland  tissue  from  which  to  reconstruct  an  ovary,  and  the  donor 
was  of  a  race  alien  to  the  reci])ient,  the  a])i)arent  local  result  of  the 
foregoing  experiment  is  at  least  noteworthy.  There  has  been  no 
change  in  the  ])atient's  ])hysical  or  mental  condition. 


*  .Xnlc     hdW     tliis    (lilTcrcd     t'l-oni     the    condition    of    llic     iniplaiited     testis    on 
removal   in  C^ase   VI I. 

—  278  — 


SJ-:x  cr.Axi)  lmpi.axtatiox 


Xo  studies  oi  the  i)li\  sioloi^ic  eti'ects  of  the  implantations  were 
made  in  any  of  the  im])lantati()n  institutional  cases,  for  reasons 
which  should  be  obvious  to  those  familiar  with  the  unfavorable 
environments  aflorded  by  lari^e  hospitals  for  the  insane,  where  even 
the  most  intelli,i(ent,  progressive,  and  enthusiastic  staff  physicians 
are  handicapped  by  (j\-er\vork  and  scanty  resources  in  the  matter  of 
laboratory  and  instrumental  ecpiipment. 

All  of  the  implantations  performed  were  understood  bv  the 
relatives  (jf  the  subjects  to  be  experimental,  and  were  done  with 
their  full  knowledge  and  consent. 


279  — 


CHAPTER  XII. 

Further  Experimental  and  Therapeutic  Work  in  Sex 
Gland  Implantation. 

Wiv  now  will  consider  more  in  detail  certain  features  of  the 
researches  recorded  in  the  ])receding-  chapter  and  record  additional 
observations  which  will  serve  to  make  the  work  more  comprehensive 
and  com])lete,  and  it  is  hoped,  even  more  convincing.  The  illustra- 
tions speak  for  themselves.  The  photomicrographs  are  confirmatory 
of  the  evidence  afforded  by  the  illustrative  drawings  already  pre- 
sented. 

Certain  experiments  upon  fowls  already  have  been  mentioned, 
without  presentation  in  detail.  A  number  of  experiments  were 
made.  Fully  comprehending  the  improbability  of  securing  marked 
results  from  testicular  im])lantations  upon  adult  subjects  castrated 
prior  to  the  full  develo])ment  of  secondary  sex  characteristics,  and 
having  in  mind  merely  the  possible  effects  of  the  sex  hormone  upon 
nutrition,  the  author  made  the  following  experiment : 

I.  Subject,  a  Buff  \V\-audotte  capon,  eighteen  months  old,  caponized 
at  the  age  of  four  months.  Weight,  nine  pounds.  Male  plumage  distinct.* 
The  almost  complete  absence  of  comb  and  wattles,  the  pallor  of  the  face, 
spiritless  air,  massive  development,  clumsiness,  lack  of  gloss  of  plumage, 
relatively  inferior  length  and  bulk  of  cock  feathers,  limited  appetite,  sluggish 
movements,  lack  of  spurs,  and  asexuality  of  the  subject  were  very  char- 
acteristic. 

April  28,  1914,  the  left  testicle  of  a  normal  cock  of  the  "butcher  shop" 
mongrel  variety,  was  implanted  in  the  left  side  of  the  pelvis — extraperitoneally 
— of  the  cai)(>n.     The  wound  healed  prompth'. 

P>egiiniing  about  one  week  after  the  imi)lantation,  the  subject  "braced  up" 
considerabh'.  The  plumage  ])ecame  more  glossy,  the  carriage  of  the  fowl 
was   more  like   that   of   the   normal   male,   and   the  appetite   and   color   were 


*  It  i.s  neccHSATY  io  defer  caiioiiizinK  \in1il  the  male  plumage  is  fairly 
wf'll  shown  and  the  testes  ar(;  siiniciontl.\-  lai\i;o  to  be  coiripai-atix-ely  easily 
foinid.  'riiis  accounts  foi-  the  iircscnci'  iil'  the  |iluinaK(;  I'ai-tor  of  the  seeoiidai-\- 
si'.v    cli.'iract  crs    hi    llu'   i,-a]ioii. 

—  280     - 


SI'.X    CI.AXl)    IMIM.AXTATIOX 

greatly  iiiiprdvod.  I'.y  the  end  (jf  tlic  second  week  the  iinprovenient  in 
condition  \va,->  marked  in  e\  ery  way.  and  nianiiudatidn  of  the  \ent  showed 
a  (Hstinct  sexnal  rellex  Nvith  characteristic  respond?  on  the  pari  of  the  sub- 
ject, le~-  iinl_\-  in   deuree  tiian  in  the  nnrnial    fnwl. 

The  iinjir' i\  en;ent  nut  mdy  did  ma  continue,  Imt  deterioratii  ^:i  occurred 
ahhouyli  at  the  enfl  of  three  weeks  after  the  implantation  the  conchtion  still 
was  better  than  prior  to  the  experiment.  The  sexual  reflex  had  almost  en- 
tirely disappeared.  Afeanwhile  several  hcteroiniplantations  of  inlands  from 
noiirelated  donors  were  done  upon  normal  fowls,  with  recovery  of  the  sub- 
jects, but.  as  sh(_>wn  b\'  sul)se(iuent  dissection.  withoiU  success  of  an\'  of  the 
imi)lantations  per  sc. 

IT.  The  left  testicle  of  a  small  mon.yrel  cock,  one  year  old,  was  re- 
mo\ed  and  replaced  b_\-  the  left  testicle  of  a  recently  killed  Black  Minorca 
cock,  one  year  old.  There  was  considerable  hemorrhas4e.  but  the  bird  ap- 
parently reco\"ered  from  the  inuuerliate  cttects  of  the  operation.*  Death  oc- 
curred on  the  second  day.  apparently  from  enteritis  with  profuse  diarrhea. 
Wound  normal.     X^o  autojjsy. 

III.  A  testis  from  a  lar.ye  Ihiti'  Rock,  tifteen  months  old — the  largest 
testicle.  l)y  the  wa\'.  that  we  e\er  ha\e  -een  in  a  fnwlt — wa^  implanted  ex- 
traperiiiineally  in  tlie  left  side  of  the  abdi)men,  ju-t  abo\e  the  groin,  of  a 
female  Ijiitt  Wyandotte,  fi\e  >ears  old.  Deatli  occurred,  probably  from  en- 
teritis, on  the  third  day.     Wound  normal.     Xo  autops\". 

In  the  carl}-  ])eri()d  of  Iti.s  work  the  author  did  a  dotthle  hetero- 
iin])laiitati(jii  ti])on  a  _\ear-ol(l  iiKjni^-rel  cock,  which  wa.'^  reported  to 
have  (hed  six  da_\s  later  from  exhattstioii  and  diarrhea.  -\.s  this 
Ijird  had  Ijceii  ke])t  ttnder  ver_\'  tiiisaiiitar\-  conchtions  and  had  heen 
half  starved  and  otherwise  al)ttse(h  and  the  operation  had  heen 
severe,  no  signiticaiice  had  l)een  ascril)ed  to  its  death.  Xow.  how- 
ever, after  the  restths  obtained  in  Kx])erinients  II  and  III.  we  began 
to  consider  the  toxic  ])Ossibilities  of  ini])lantation.  and  were  perti- 
nently reminded  of  the  ])henomena  of  anaph\laxis.  said  to  result 
occasional!}-  from  various  serttms.  and  which,  frankly,  the  author 
had  not  believed  to  be  dtte  to  ])rotein.  btit  to  some  other  sertim 
content    ])r()dticing    toxemia.      Acute    se])sis.    dotibtless.    practicallv 

*  Till'  aullif)!-  has  nut  \'<'t  siu-cetM'u-d  in  iK-n'tM-t  iiiK  a  satisfacl(>r\'  tcH-liiiic 
!'nr  i-a.strat  iii.u'  adnlt  hirils.  The  ribs  ar'>  tli-ni.  the  testes  too  .soft  to  endure 
ima-h  iiianiiMilaliiin.  and  tlie  \-oss<ds  (|nitc  hir,t;<',  the  arteries  roniiiii;-  almost 
flirectl.\'  from  tlie  aorta  and  tlie  ^■eins  eniiit  .vint;'  directl\'  into  tlie  ^"ena  eava. 
'rile  Vessels  also  aio  \-ei'\'  t'l-a^ile.  \\-itli  the  exeeiition  of  the  suh.ieet  used  in 
lOxjierirneiii  II.  all  ha\'e  died  of  hennuaiiaue  on  tlie  oiieratins-  table.  'J"he 
ojiefation  is  sUK,i;est  i\'e  (jf  what  reinoxa!  id'  the  linniaii  kidney  would  be  with- 
out   eas\-   aeec-ss    or   means    for   eont  rol  lins"   hieinori-has;"e. 

t(»ffliand.  tile  authei'  wajtild  :;a,\-  that  a  luiman  testis  of  the  same  relative 
size  would  weiyli  lietweeii  two  and  lliree  ihiuikIs.  'fhis  is  to  sa.v  muhintr  of 
tlie    telat  i\el.\-    greater   aeti\it>-    of    tlie    inland    in    fowls. 

—    2S1    -- 


IMPOTENCE   AND    STERILITY 

could  be  disregarded  in  our  experiments,  as  fowls  tolerate  opera- 
tions well,  where  severe  hemorrhage  can  be  avoided.  When  properly 
performed,  caponizing  in  young  fowls  does  not  show  over  one  per 
cent,  of  deaths,  and  this  from  shock  and  hemorrhage,  or  hemorrhage 
alone. 

To  determine  the  following  i)oints :  1,  The  effect  of  successive 
implantations  on  the  same  subject ;  2,  the  effect  of  implantation  of 
the  male  sex  gland  upon  the  female ;  3,  the  effect  of  large  doses 
of  gland  tissue  upon  the  female  ;  4,  the  effect  of  alien  protein  from 
the  fowl's  testicle  U]K)n  a  higher  animal ;  the  following  experiments 
next  were  made : 

IV.  Alay  21,  1914,  the  companion  testis  of  tiie  one  used  in  Experiment 
111,  was  implanted  in  the  right  side  of  the  pelvis — extraperitoneally — of  the 
came  capon  used  in  Ivxperiment  I.  The  Ijird  seemed  indisposed  for  forty- 
eight  hours  after  the  implantation.  He  then  rapidly  recovered.  May  29th, 
the  color,  general  carriage,  lustre  and  carriage  of  plumage,  spirit,  activity 
and  ai)petite  all  were  more  than  ever  like  the  normal  characteristics,  although 
hy  no  means  up  to  standard.     The  sexual  reflex  reappeared  in  slight  degree. 

August  24th,  a  slight  further  improvement  was  noticeahle  in  the  various 
])oints  mentioned,  save  as  to  the  sexual  refle.x,  which  had  disappeared.  The 
hird  was  much  more  active  than  ever  and  showed  signs  of  combativeness, 
fighting  a  little  with  strange  males — who  ver\'  ])romptly  attacked  him.  This 
latter  point  is  imjjortant,  inasmuch  as  normal  males  at  once  recognize  the 
capon  as  in  no  sense  a  rival  and  rarely  annoy  hiiu.  The  subject,  as  before, 
showed  no  disjjosition  to  approach  the  female  sexually. 

About  the  middle  of  November,  1914,  the  capon  was  found  fighting 
quite  savagely  with  another  bird  through  the  lattice  of  his  coop,  and  sev- 
eral times  was  heard  to  crow  distinctly.  The  subject  still  showed  no  disi)osi- 
tion  to  approach  the  female  sexually.  Shortly  after  this  the  bird  was  accident- 
ally killed. 

That  a  marked  degree  of  physiokjgic  regeneration  occurred  in 
this  case  is  evident.  So  far  as  it  goes,  the  experiment  also  tends  to 
show  the  safety  of  successive  implantations.  Obviously  the  dose 
was  much  larger  than  in  httman  implantations.  Reimplantation  in 
the  human  subject,  if  done  at  all.  would  be  performed  only  after 
a  considerable  interval,  and  considering  this  ])()int  and  the  resttlts 
of  the  experiment  on  the  capon  may  be  regarded  as  safe.  A  note- 
worthy ])oint  is  the  continuance  and  slowness  of  the  ])rocess  of 
regeneration.  That  there  should  have  been  in  the  ca])on  any 
awakening  whatever  of  dormant  sex  characteristics  is  remarkable. 

'^I'here   is   a   vast   difference  between   implantation   upon    (a)    a 

.  282 


v^l'.X    CI. AM)    IMLM.AXTATIOX 

\()un,L;'  male  lliat  has  recently  ]k\-\]  castraled  or  one  that  has  heen 
castrated  after  full  maturity,  and  (  h  )  a  male  that  has  heen  castrated 
earlv  and  has  arrived  at  full  maturity.  The  difference  lies  in  the 
fact  that  in  the  one  instance  the  secondary  sex  characteristics  may 
continue  to  s^row  or  are  already  develo])ed,  while  in  the  other  the 
secondary  sex  characteristics  never  have  develo])e(l  and  regenera- 
tion is  very  difficult  of  accomplishment.  ( )nce  ])S}chosexuality  has 
developed  mid  impressed  the  animal  durins^'  the  ])eriod  of  growth. 


Imr.   1. —  Capon  used  in  e\]K'rimc'nts  T  and  T\'. 


the  results  of  its  intiucnce  remain,  oven  though  sex  power  and  de- 
sire completely  disap])ear.  IJoth  sex  power  and  desire  may,  how- 
ever, remain  for  a  variahle  ])eriod  after  complete  castration  in 
adults.  \Micre  they  remain  in  young  animals,  the  explanation 
usuall}'  is  an  incom])lete  operation.  'I'he  author  recalls  an  instan.ce 
of  a  gelding  that  was  castrated  late,  who  served  mares  as  normally 
as  could  any  stallion,  llere.  the  o])eration  ma\-  or  ma\-  not  havi: 
heen  com])lete.  A])ro])os  of  this  point,  the  high  valuation  set  in  the 
( )rient  upon  eunuchs  who  have  suffered  complete  ahlation  of  the 
genitalia  is  readily  understood. 

—  283  — 


J.MI'()TENCr<:    AND    STl'.UII.lTY 


Fis^'.  2. — Normal   full  brother  of  cai)on  shown  in  I'ig.   1. 

It  is  ])i-()bal)le  ihal.  in  the  experiment:  on  the  ca])on,  verv  little 
of  the  implanted  tissue  surx'ixed,  }-el:  it  nnist  have  been  snlhcient 
at  least  to  set  the  regenerative  ])rocess  in  motion.     The  a])])lication 


'*'%ll 


TL'^'» 


Fi-r.    ;■!.-  Section   of   iit.iinil    |,Mi~   ..t    c,  l,i,l    iuui    iiionlli-    (.1,1,    >li.i\viri^-   cli.-inicli'i-isl  ii'ally    ^rcat 
iil>iiii(hiiic('    .,f    i,MHMlixc    yl.iiMl    h-Mii-    llihiih    ^.  iiniiif.  n'l.       A,     l.'iillcil    up      cylinder-like-  - 

scjmcnl     iif    (li  Ik  il(      pi  i  iIi.im  ,i  1     inM-lni(nl,     (..iic^i ilin^;-     li.     the    \  iscci\il     laxcr    of    the 

III,,;,;,  ,-,i,i!,ii,h.<  :uhI  the  l,i,ii,;,  iill.ii ,,i in  ,i  ot  tcMi-  ot  lii-hci-  aniinaN.  H.  M.-nle-^lis,  /.  r.. 
pen'toiMMJ  folil  lit  i-piili<hnial  holder  of  j;-!:!^!.  This  is  almost  as  ilclicate  as  a  coliwch. 
C,    Tn\,nli   s,  „,,„,],,■■,. 

—    2.S4    — 


SI-.X    CLAXi)    IM  n.AXTATIOX" 

of  this  to  human  hornioiu-  tht-rapx  i--  cxiik-iit.  'IMu-  test  in  tlii-^  case- 
ol)viotts!\-  was  tlic  scvcrot  i)o>>il)k;. 

h'i.^s.  1  and  2  show  the  more  imiiortant  (hlTerences  in  the  aj)- 
l)earance  of  the-  head  of  the  caponizecl  and  of  the  nncapcjnized 
fowl      Tile  hirds  are   ftill  hrotliers  of  {hv  >ame  a,^e. 

\'.  An  exceptionally  lar.iic  te-tis  iri>ni  a  nicin.urel  cock,  one  year  old. 
and  a  small  te.-ti>  I'roni  a  White  l,e,L;liorn  cockerel,  fotn"  months  old,  were 
implanted  in  the  ri,L;ht  >ide  of  the  pclvi>  -extraperitoneally — of  a  lhor(.)UL;h- 
hrcd  ki.iilu  i'.rahma  pullet.  I'oiir  nioiithi  old.  At  the  same  time  the  com- 
panion testis  of  the  younii  ke.Lihorn  was  implanted  in  the  pullet"s  left  hreast. 
That   the   dose   (.)f   .yland   ti^^ne   was    :,'normons    is   ohvioiis. 


Healin.y  was  ])ronipt  and  the  -uliject  was  continuously  normal.  Sev- 
em\-tive  day.-  after  im])lantation.  the  jiullet  wa>  killed.  Autop-y :  liody  ex- 
ceptionally ]dunip  and  well  iiouri.-lied.  Or.uans  normal.  Xo  vestiiic  of  the 
uland  implanted  in  the  hreast.  Tho-e  imi)lantcd  in  tlie  pelvis  were  livinti".  and 
plainly  reco.nnizalde  as  teste-.  \'a>cular  supply  macroscopically  abundant. 
\  essels  oi  attachment  between  the  two  int])lanted  .ylands  macroscopicall\' 
\isible.  The  lar.yer  .uland  was  a  lirm  Ijuticular  body  about  2  cm.  lont^'.  15  mm. 
wide  and  1  cm.  thick.  W'ei.Liht,  ,1.05  .yram.  The  smaller  testis  was  especially 
\ascular  in  it>  en\ironmem-  and  its  "testicular"  conformation  especially  plain. 
It  nic.'i-iu'ed  a])pr' iximatel}  1  cm.  in  leui^th.  f)  nnn.  in  width,  and  5  mm.  in 
thickne--.  beinLi  abont  two-thirds  its  normal  size.  \\\-i,L;ht.  0.6  gram.  The 
niicr^-copic  characters  of  the  iniplaiUed  organ-  are  shown  in  Figs.  1()_  H,  12. 
1.1  and    14. 

—  285  — 


l.MPOTKNCIC    AND    STP'.KIT.ITY 


Kij?-    ■">.      .S<ch'oii   of  iioniKil    (cslis   of   Ixiy   of   foiirleeii   ycnrs.      A,    TiDiira   alhin/ifira.      15,    Tiihiili 

Kinniiiirri. 

VI.  All  exceptionally  lart^e  rii^lit  testis  from  a  mongrel  cock,  one  year 
old,  was  implanted  extraperitoneally  in  the  abdomen  of  a  lUiff  Wyandotte 
laying  hen,  one  year  old.  Healing  was  prompt  and  that  there  were  no  evil 
results  is  evident  from  the  fact  tliat  the  subject  went  on  laying  as  if  noth- 
ing had  happened.  This  is  important,  as  the  slightest  abnormal  condition  of 
health,  and  even  slight  nervous  disturbance,  such  as  changing  to  a  strange 
coop,  usually  checks  egg  laying. 


i^mmm^mf  mW^^9  ^"""■fc      ■.WF-'  4B.  « 


l-'ifT-     <'<■-    .Sciiiiiiifrn,ii>     lulMilc     (. 


iiil;'      IMlil.      -hnwiii; 


iiuiiili<r     cf     iiiini;i(iir( 


—  286  — 


Sl'.X    GLAXl)    JMi'l.AXTATIOX 

A  fiiul  imrpi  H-lin;^  tn  lie  the  same  as  the  Milijeel  of  l-'xperinient  \']  was 
killed  three  inonths  later.  .\iitc)j)s\'  showed  nonnality  throutiliout.  l)ut  no 
traee  of  the  iiii])laiit  .■<!  ^laiid.  .As  there  was  not  even  a  \estit4e  of  scar  or 
eoiiiiecti\'e  ti-sue  at  the  recorded  >ite  of  implantation,  the  autiior  is  in  doubt 
as  to  whether  or  not  some  nii>take  in  tlie  identity  of  the  snhject  was  made. 

.\s  far  a.s  ])()iiits  1,  2.  and  o  are  concerned,  the  results  of  the 
fore.i,''!  lin.L;'  e.\i;eriinents  seem  (jtiile  conchtsive.  In  the  case  of  the  hen 
tised  in  h'xperiinetu  111,  old  a,^"e  prohahl)'  had  intich  to  do  with  the 
result.  The  ])ossil)iHt_\-  that  a  lari^'e  do>e  of  hornione  from  a  rela- 
ti\-elv  \-ounn'  ,^"land  ma_\'  have  heen  the  disastrous  factor  is  frcelv 
admitted,   hut.   I'-rantint''  this,   no   such   result   cottld   occin-    from   the 


7.  'I'l  ;ii]~vcr>i-  Mctinii  <.f  ('ijiiliilviiiis  nf  a  vdhh^-  r 
.\l:i--;(-  nf  ci.aLi-iilatrd  -ciiicii  are  seen  within  llic  ti.lnili 
"Ui.    !ia\-iiii;-    ihc    Imiaii    '.f    the    tulmli    clrar. 


sli.iwiiii;-    tralK-cul;c    ami    tubuli. 
line  lit   tlie<e  Inass(.^i  liavu   fallen 


relati\-e]y  >mall  dose  restiltin,!^-  from  im])]antation  in  the  htiiuan  suh- 
ject.  The  other  fatalities  ])rohal)l\-  were  due  to  coincidental  cattses. 
with  due  re_qarfl  to  the  possibility  of  individual  predisposition  and 
the  remote  effects  of  shock. 

Iv\])eriment  \'.  as  shown  h}-  the  luicroscopic  appearances  of  the 
removed  .glands  nearly  three  months  after  implantation,  and  by 
sul)se(|uent  histolo,^ic  sttidw  demonstrated  also  the  success  of  the 
implantation  per  sc.  confirming-  the  results  obtained  in  otir  ])revious 
experiments  on  the  human  subject  (  I'i.^'s.  15.  16.  17.  and  18).  That 
.^uch   remarkable  results  should  accrue    from   implantations  of  male 


IMPOTKNCE   ANJ3    STERILITY 


Fiy.    8. — Iiiterslitii\l    (iii(citiil)iilar)    connective  ti^isiie  of  ein'didyniis  of   a   \'Oung  ram. 
Compare   willi    l'"it;>.   '.),    M,    17    anil    JS. 


glands  upon  the  female  is  not  so  astonishin,^-  as  it  may  seem  at  first 
sight.  The  l)lood  of  the  female  is  excellent  ])abuluni  for  every 
tissue  in  the  body,  as  witness  the  development  of  the  fetus  ui  utero. 


*  ^r^  ^ 


ri^f.  fi.  Seclion  of  (lie  body  of  tl^tl^  of  .1  \onni;  i.im  V.  Tnteistitial  (inlei'tuliidar)  eoiniectivo 
tis-<uc.  H-C,  'riihiili,  xriii  i/ii  I' 1 1 .  ^liowinf;  s((iifoi^  I  [jitlic  Innn.  Compare  witliFigs.  S,  1:2, 
17   and   18. 

__    2SS    -^ 


SI'.X    (M.AXI)    LMIM.AXTATIUX 

Wl.  As  to  point  4:  A  very  larLje  left  testis — companion  to  that  used 
in  IC.\i)erinient  \'J--\\as  iniplanicd  in  the  left  ,nr<iin  (jf  an  Airedale  terrier, 
three  months  old.  J.ocal  anesthesia  was  employed,  with  more  attention  to 
asepsis  than  in  the  case  of  ihe  fowl^.  althnu.uh  the  technic  wa>  hy  no  means 
all  that  could  he  desired.  I'rimary  union  occurred,  hut  on  the  fourth  day 
sl(.)usj:hin,y;  of  the  su])erricial  tissues  of  the  ahdomen  het^an,  and  hy  the  seventh 
da\-  nearh'  the  entire  ahflominal  wall  was  denuded  down  to  the  muscular 
aixMieurosis,  nccessitatinti'  the  killinj^  of  the  animal. 

I{\-en  after  niakin,*.^'  elite  allowance  for  greater  facilitv  of  in- 
fection, the  fore^t^oini^-  result  was  in  striking"  contrast  to  that  obtained 
in   fowls.      In  a  large  miniher  of   fowl   implantations   we  have  seen 


I'il.^-.  tiK  -Section  of  (csti^  of  n  fnc-l<ci-('l  four  iiioiitli<  old.  iiii|)laiii(><l  in  nii  iinrchitcd  pullet,  four 
nioiiili-^  old.  mid  roiiiovcd  .it  llic  cud  of  so\('iity-li\c  d;i\s.  (KNiicriiiicut  \.  )  A.  Ordiunry 
tiliroi-oi.ucclivc  tissue  ;il  Ihe  pei-ipheiy  of  the  ^■hmd,  eiiir<.spoudiiit;-  lo  ils  peritoneal  tunic. 
B.  Aliuiidaully  ijrolifc  rated  ititei-st  it  ial  eouneetive  tissue,  with  a  luoderale  aiuouiit  of 
oi-dii!ar\-  eouneetive  tissue.  ( '.  Itcniains  of  the  hihiili  sriiiiii  if:  ri .  not  yet  Hi-ud.\-  ofsani/.ed 
via  eoiuieetix'e  tissue  jU'oliferat  ion.  .\ I  i|s  inferior  liorder  is  seen  a  new  ea|iillai'\.  show- 
iiii;'  that  the  d(  ii'eiierated  mass  of  triu>  seeretini;'  tissue  is  li\iny.  Compare  with  Ki^'s.  11. 
\-l.     I  I    and    1(1. 


but  two  cases  of  infection.  These  were  i)itrel}-  local  and  chronic, 
consisting  of  a  had  smelling  fnngtts-like  growth  with  slight  snp])ttra- 
tion,  and  no  deterioration  of  general  health. 

It  is  \\-orthy  of  conimeiit  that  the  relative  degree  of  traitmatism 
in  im])lanting  adult  testes  in  fowls  —  es])ecially  voting  ones  —  is 
immensely  greater  than  that  involved  in  im])lantations  in  the  higher 
animals.  In  lowls  the  im])lanted  gland  is  so  large  that  it  presses 
considerably  on  the  tissues  of  the  implantation  bed,  and  even  on  the 

—  289  — 


IMPOTENCE   AND    STERILITY 

viscera.  Fowls,  moreover,  are  relatively  insensitive  to  injuries.  As 
to  the  "alien  species  ])rotein"  factor  in  the  foregoing  experiment, 
\vc  confess  that  we  were  somewhat  in  douht.  Since,  however,  his 
recent  extensive  experiments  wuth  organic  emulsions,*  the  author 
has  felt  reassured  on  this  point. 

In  a  numher  of  ex])eriments  in  "exchange"  transplantations  in 
both  unrelated  and  related  young  cockerels,  we  apparently  have  met 
with  hut  one  success  in  ])reserving  the  secondary  sex  characteristics, 
although,  in  every  instance,  thev  developed  much  better  than  they 


Fiy.  n. —-Section  of  testis  of  cock  one  year  old,  implanted  in  an  unrelated  pullet  four  months 
old,  and  removed  at  the  end  of  seventy-five  days.  (Kxperiment  y .)  A-15,  Subcortical  area 
showini;;'  completely  organized  connective  tissue,  mainly  of  the  interstitial  variety,  but 
coiitaininf>-  ordinary  fil)roeoimect  ive  tissue  in  small  amount.  An  abundance  of  new  vessels 
tilled  with  normal  lilood  nia\-  \n-  seen.  ]?  shows  the  actively  regenerating,  but  not  yet 
l)ermaiiently  organized  interstitial  tis-<ue  at  the  border  of  the  medullary  portion  of  the 
gland.     (,',   negenr'rated  tubuli.      I'eiijiliei'x'  of  gland  not  shown. 

did  in  control  capons.  It  is  ])ossible  that  different  results  may  be 
ol)taine(l  from  implantation  of  unrelated  adult  testes  on  young 
fowls.  Tbe  details  of  all  our  various  ex])eriments  would  here  be 
su])erHuous.  Two  of  these  ex])eriments,  however,  are  of  especial 
interest. 

\'Iir.     The  testes  of  a  Li^lit  r)raliina  coekerel.    four   months  old,   were 
removed  and  replaced  l)y  those  of  a  White  Leghorn  of  the  same  age.     The 


♦  IOx])Orinifiits  with  lOmul.sion.s  of  Organs  Taken  frdiii  the  Dead  lliimaii 
l!i)(l\-  ;iiiii  Sex-  Clauds  ol'  the  Lower  .\iiiinals.  .\nierieaii  .Medicine,  l)eceinl)er, 
lltl  1. 

—  290 


SF.X    CLAXl)    I.MPI.AXTATIOX 


I'ii;.  \2. — Aic;i  .if  xcli'iii  (l(]ii(ti  il  in  l-"in'.  11  iiiidi  r  liiulii  i'  linwcr,  showing  ubmulaiit  pi'n 
lifci-ati.iii  ...r  ilic  iliai.ieu  ii>lic  inldsUtial  tclN  in  testis  ..t  imi.1;  imij  year  old,  iuiplaiitrd 
ni".n  a  ,\..iin:;-  iini-clatcil  li-inalc  ami  imioxcil  at  tlic  end  uf  s(\  i-nty-five  days  (I-^xpiTi- 
inciit  \'.)  Tile  iiornial  h]'n„\  c^inli-iit  ..f  the  niiincr.iiis  \i--i'Is  is  jdaiidy  socii.  Tlicff  ap- 
]iaiTml\-  is  \i\y  litllo  fil.ix;c"iiiii  It  i\c'  ii~s!;(^  -iiid  tliis  i~  --iiiuitid  cliicMy  ill  the  viciiiily  of 
llic    vessels.     (  Minj.are    with    I'ii;-.    s.    !i,    lo_     17    -md    Is. 


Im\'.  l::.--.Sei'li'.ii  ,,f  testis  ,,f  ewcl;  one  ,\-ear  "Id,  iniplaiiteil  ^n  an  uiifelated  pullet  f.Mif  uiomli: 
"Id.  and  iciii"\cd  at  the  end  "f  se\iiitydi\  e  da.\  s  (  l-'.xpiaanient  \'.)  A.  Oi'iliiiaf.\'  e"n 
neeti\-e  tissue.  (-"iTesp.  .ndi  nn'  t"  the  hK-alicm  nf  the  pefiteiieal  tesiieulai-  investiueiu .  ]5 
SuheMi'tieal  la.vff  nl  aliiualant  ].\-  iii-e.lifei-at  int;-  iiil  ei'-t  i  I  ial  (  intef-tiiliular)  C(.iiiieel  i  ve  tissue 
with  a  -iiiali  aninunt  "f  the  erdiiiary  vaiiet.x-.  ( '.  I'i'niianenil.\-  iiru'anized  iiitei'stil  ial  lis 
■sue,  with  a  moderate  aiiiounl  e^f  onlinaiy  hlu'oeeniie't  i\e  tissue,  riehly  supplied  with  new 
Mood    \essels    eontainint,'    lainnal     hhiod. 

—  291  — 


TMPOTENCK    AND    STERTTJTY 


[•■i^-.  II.  Scctidii  of  K-ti-  til. Ill  (o(l^.  (iiic  \(,ir  iiM,  iiiiiiliiihd  tni  v,  m  nl y  I'nc  ilnys  in  :iii 
iiiircl.'iti'ii  piillcl.  tiMii  iiiDiillis  old  (  i:\|i(  I  iim  111  \  ).  s|i,,\\iiii;  |m  i  iii.iiu  iil  ly  ori^iiiiizcd  intcr- 
sliliiil  (iiilcrliiliiil.il)  loniKiliM  li^viii.  ,111  .iliiiiid.iiil  supiih  ,,t  luw  Mc.od  \csscls  coiitniii- 
iii.i;'  iioMiial  lilond,  .iiid  nil, iK  i  oils  l.ii^c.  (hiph  -.Iniiid,  loimd  .md  o\oid  bodies  const  it  lit  iiiK 
dcyciicnitol.     hut.    -nil     Iniiit;,    lilmli    -(iimiiliii 


Fiy.  i:i.  Sri-lioii  of  tcslis  iviiiovcd  fvoni  iiiiili  of  lliii'l.\-  yc;ii-s,  .lend  icii  liouis  fmiii  iM)iit:ict 
"■illi  .1  li\c  wire.  Chiiiil  M'fi-iyvviilcil  foul'  diiys  in  .111  ordiiiiiry  ice  liox  iiiid  iiiiphinled  ill 
tile  :il)doiiiiii;il  \\;ill  ii|Miii  llie  a  1  loiicii  losi  s  of  llii>  riulil  recliis  in  llic  liypof^asl  rie  rciiioii  of 
an  iinrclalcd  female  senile  dcliielil.  a^'cl  sixly  yiar-.  Claiel  rciiioxcd  afler  four  iiionllis 
and  nine  days.  A,  Tiinird  iil  Inn.i  11,  a .  -li.  iw  iiii;'  clia  raeterisl  ic  lilivoeoniiect  i  vc  tissue  and 
Idood  \-cs-cls  (1m, 111  (,1,1  and  11,  \v).  I!.  Sol  ,c,  ,rl  i<  .1 1  siraliiiii  of  pr,  ,li  fciatcil  iiitcrst  il  ial 
( intiTliiliulai-)  li"iie.  c,  ,nl  a  in  inn'  an  aiiiinilancc  ,,f  new  l.lo,„l  \cssels.  Here  and  tlierc  in 
tlie  nia>s  ,,f  inter-liiial  I  i-siie  nr,.  seen  llie  ,larK.  ili-l,,ii(d  ,,iilliiii's  .,f  liiliiili  sr  1,1  iiil  I'lri . 
which  have  l„<n  "si  1  an-led"  out  and  ivplacl  l.y  the  inl.ast  it  ial  cells,  lor  tile  dcvidoli- 
nient  ,,f  which  llii.  iiil,iili  siMinin-K-  f,.riii  an  e\cell,iii  iiia!|-i\.  The  line  ,jf  ilcinarcal  i,«n 
lielwicn    llie    Iw,,    kiii,l>    ,,f    lissiu-    is  '  pl^i  iiil.\     disccrniMe. 

292 


S1-:X    CI. AND    IMI'F.AXTATIOX 

reci])icnt  nialurcd  with  s^reat  rai)idity — compared  with  uthcr  males  of  the 
same  strain — as  to  color,  weight,  comb  and  wattles,  plumage,  carriage  and 
what  is  termed  \)y  fanciers  the  "talking  \'oice."  which  within  two  weeks  was 
transformed  from  the  "peep"  of  the  _\-onng  fowl  into  the  lK)arse  notes  of  the 
adult.  'J'he  l.)ird  became  more  si)irited  and  combative.  The  testes  of  the 
Brahma  were  imi)lanted  in  the  normal  position  in  the  Leghorn,  who  siihse- 
qnentl\'  showed  all  the  usual  characteristics  of  the  capon. 

The  etfecls  of  the  implantation  on  the  Brahma  graduall\'  disap])eared. 
and  lie  now — seven  months  after  the  removal  of  the  testes — resembles  a 
capon   ca-traled   rather   late.   ni;irkedly   conforming    witli   uncastrated   males    in 


Hi,',  ic,.  -S((ii.iii  t  1(^11-  til  111  111  111  IT  tliiu\  \tii^  ill  1  1  liii  li  HI-  innii  ciiiitact  willi  ;i  li\e 
wire,  inipl.iiiii  I  11)1  II  III  iiniiluiil  ti  in  ili  (  1  mil  niiuii  iti  1  t  iiv  iUi\-s.  Itciiioveil  finir 
iii'iiilli-  ami  mill  iln-  ithi  iiii|  I  iiit  it  i  ii  \  Iikhh  nlhin/  ii  a  -hnwiim-  uriliiiary  tilirn- 
C'liiiiul  i\i'  ti--iu  iml  I  1  I  il  \i  — 1  N  I)  siiiiiiiiiit  (  ii  11  II  ti  I  i-t  (  interstitial  (iiitcrtiil)iilar ) 
tissue.  iil)Maifi]\  -li  w  iiu  ili-tmli  il  aitlim-  t  l.-iliti  /  Ijiil  v  in  inlfrri .  with  abmiiluiit 
siip|il\-  lit  l)Ii  1  \i—  I-  (  Siiiiiiiil  luliiili  till  -  lilt  i\  (  iHllii  liiiiii  lit  which  has  ilis- 
aiipeai'iil— plaiiih  ii  iiliil  iml  iiiiiiiivt  ik  ihli  In  ihi-  ]iiiiiiiilii  ilea  tlii>  tiihuli  look  the 
stain  in  vrvy  n  iliiiti  ili_iii  Imi  i|I1i|i  i-  will  it  will  K  li-ti\eil,  as  iliil  the  iitiiiiie>- 
ti'jiialily    livini;-    liii,u;i    <,lhii,in,.<i. 

everything  save  crowing  and  sex  activity.  The  diti'erence  in  results  in  the 
two  birds  ])robably  was  due  to  the  relatively  early  develo])menl  and  great 
activity  of  the  sex  glands  taken  from  the  Leghorn — one  of  oiu"  best  laying 
breeds — comparerl  with  tlio.st,^  taken  from  the  Brahma,  a  breed  which  develops 
sex  characters  \  c-r\    -li  ,\\  K.  ■ 


*  It  is  iiiti'ta-st  iiij4  til  imti'  till-  iiiliiiKiir  rclaliuii  uT  railx'  .■mil  luarki'il  sex 
.Ubiliil  ili-\i'luiiiiii-'iit  In  till'  ^I'cMl  111  \-iii,L;-  i-;ip;icil  .\-  iil'  vai-imis  fnwls.  What  is 
inic  i\\'  llii'  li-slis.  also  is  triU'  nl'  tin-  n\ar.\-.  Tin-  pnssil  lil  i  1  >-  ul'  impfiu' iti.t;-  tin" 
Ia\  iliK  i|uali!ics  ami  li-iiilitx  i  I'  xaiiuus  sliaiiis  li.\-  scX  ,t;laii(l  implaiita tiniis 
11  pull   nn  rill  a  I    hii-ijs  a  I    diici'  svt,t;i;i.>st  s  il  self  and  max'  jirox-e  of  i  lit  crest  to  IjrtM.Hleps. 

—   293   — 


IMPOTENCE  AND   STERILITY 

IX.  May  15,  1914,  we  removed  the  testes  of  two  White  Orpington 
cockerels — half  brothers — three  months  old,  and  implanted  the  testes  of  one 
subject  upon  the  other,  in  the  normal  site  of  the  testes,  leaving  one  bird 
caponized  for  a  control.  December  11,  1914,  the  implantation  subject  was 
examined  and  found  to  be  a  splendidly  developed,  normal  male,  with  all  the 
secondary  sex  characteristics  perfect.  He  is  active,  very  pugnacious  and  per- 
forms his  sexual  function  just  as  would  any  normal  male  fowl.  The  capon- 
ized subject  showed  fairly  well  developed  secondary  sex  characters  and  while 
more  active  than  is  usual  with  capons,  presented  a  marked  contrast  with  the 
implanted   subject. 

The  histologic  study  of  sections  of  the  implanted  fowls'  testes  removed 


17. — Section  of  another  aii'a  of  same  testis  from  which  Fig.  IC  was  tal<en,  showing  still 
more  clearly  the  living  hut  obsolete  tubiili  seminiferi,  which  gradually  arc  being  dis- 
l)laced  and  replaced  by  the  interstitial  (intertubular)  connective  tissue.  The  outlines  of 
the  tul)uli  which  already  have  been  completely  engulfed  in  the  abimdant  cells  of  the  inter- 
stitial tissue  still  are  discernible,  whilst  some  of  those  at  the  borders  of  the  area  of  the 
tubuli  which  are  not  yet  completely  enmeshed  in  the  cell  network,  are  more  plainly 
visible   than   those  which   are  not  yet  greatly   encroached   upon. 


from  experimental  subject  V  ])ro\ed  very  interesting  and  instructive.  To 
facilitate  the  study  of  these  and  of  other  implanted  glands  reported  in  this 
chapter,  and  for  tlic  purpose  of  comiJarison  will  be  first  ])resented  several  sec- 
tions  of   normal    testes. 

\'\'^.  4  represents  ;i  \ery  iiitereslin^-  si)eeinien  as  .showing-  the 
perfect  (le\x'l(»])inenl  of  tlu'  e])i(]i(l\ mis  and  of  the  testicttlar  strticttire 
l)roper  in  an  extreineh  sniall  .gland  from  a  \-er_\'  yotmg"  stibject.  1  he 
epi(li(l}niis  was  not  niaeroseopieallv  recognizal)le.  Coni])ai"ison  of 
J'"igs.  3  and  4  witli  V\g.  5  demonstrates  the  relative  great  richness  of 

—  294  — 


SJ'X    GLAXI)    IMi'LAXTATIOX 

the  generative  ^-land  tissue  of  the  fowl  contrasted  with  that  of  the 
human  suhject. 

Jn  his  iirst  contrihution'^'  the  author  stated  that,  despite  the 
statements  of  ]\Iarsliall  and  1  lanunond,  he  Ijeheved  that  the 
epidich'uiis  pr()l)ahly  plaxed  at  least  a  minor  role  in  hormone  ])ro- 
duction.  'J'he  photomicroi;ra])h  (Fi,^".  8)  seemini^iy  confirms  this 
helief. 

]t  is  interestini^"  to  note  the  distinct  lines  of  demarcation  be- 
tween the  strata  of  the  various  kinds  of  tissue  (A,  B,  C)  in  the  fore- 
going section  and  in  certain  of  those  which  will  follow,  'i'he  in- 
terior of  the  gland  probably  was  not  necrotic  in  the  true  sense  of 
the  term,  but  was  not  yet  organized  and  was  so  soft  that  it  fell  out 
of  the  section.  This  often  hai)pens  in  making  sections  of  ])erfectly 
normal  glands.  It  \\\\\  be  ol)served  that  the  characteristic  a])])ear- 
ance  of  the  interstitial  connective  tissue  in  stratum  P)  is  ])lainest  just 
beneath  the  cortical  layer  of  libroconnective  tissue  and  just  at  and 
above  the  line  of  demarcation  se])arating  l->  and  C.  It  will  Ije  seen 
that  this  histologic  feature  is  ])r()minent  in  all  similar  sections — from 
both  fowl  and  human  being — exhibited  herewith.  This  ])articular 
phenomenon  is  ex])lical)le  by  the  greater  circulatory  activity  and 
consequent  better  nutrition  at  the  points  mentioned.  .\t  the 
])eriphery,  notably  adjacent  to  the  pia  viaicr  testis,  or  tunica  vascit- 
losa,  conditions  especially  favor  tissue  regeneration.  A  certain 
amount  of  ordinary  connective  tissue  is  found  in  the  im])lanted 
glands,  a])parently  derived — as  shown  in  Figs.  8,  10.  11,  12,  14,  and 
15 — not  from  the  tunica  propria  of  the  gland,  but  from  the  septa  of 
the  gland,  of  which  the  corpus  lii(jlinioriaiiuin  is  the  most  iin])ortant, 
and  ])robably  also  from  the  walls  of  the  blood  A'cssels  (  b'igs.  9  and 
]2j.  Hy  far  the  greater  ])art  of  the  new  tissue  is  com])()sed  of  ])ro- 
liferated  characteristic  interstitial  ( intertubular  j   cells. 

What  is  going  on  in  the  mass  of  degenerated  tubuli  in  the  in- 
terior of  the  gland,  and  its  hnal  result,  is  well  shown  in  Figs.  14, 
15,  and  16. 

The  richness  oi  the  new  blood  sup])ly  of  the  implanted  gland  is 
well  shown  in  l^'g.  11,  and  in  the  next  folkjwing  of  the  series  (12). 
Fig.  12  also  demonstrates  conclusivel)'  that  the  regenerated  tissue 
is  not  composed  of  (ordinary  libroconnective  tissue — save  in   small 

*  N.   Y.   :M('(].    Jour.,   Mar.    lil,   April   4,   .July   n,    1911. 

—  295  — 


IMl'OTluVCIi   AND    ST]\RTLITY 

anu)unl — but  of  what  ma}'  l)c  inferred  to  be  tbe  cbaracteristic  inter- 
stitial cells.  This  tissue  ])]ain]y  is  present  in  the  implanted  glands 
in  far  greater  amount  than  in  the  normal  gland.  This  perha])s  is 
the  most  im])ortant  ])oint.  The  character  of  the  regenerated  tissue  is 
witnessed  by  Figs.  12  and  17. 

The  ([uestion  of  whether  or  not  the  degenerated  tubuli  of  the 
testis  may  retain  their  vitality  after  they  are  functionally  dead 
from  destruction  of  their  gland  epithelium,  would  seem  to  be 
answered,  not  only  by  their  retaining  their  form  sufficiently  to  be 
recognizable  after  a  long  period  of  time,  but  also  by  the  manner  in 


Fig.  ]S.-  Section  of  testis  iiuiilniited  in  the  sii]>r;iinil)ic  i-e^-ion  of  a  wonuin  sixty  years  of  age, 
and  renio\e(l  at  tli(>  <  nd  of  four  iiioiitlis  and  nine  days.  A-l!.  ()l)Solete  but  still  living 
tiihiili    sciiiiiiiffri.       (',     Interstitial     (inteiluliular)    cell    i)ioliferation. 


which  they  stain.  (See  especialK'.  Fig.  17.)  Fig.  14  is  a  ])ertinent 
illustration.  The  remnants  of  the  tubuli  took  the  stain  so  well  that 
they  had  the  appearance  of  small  ])lums.  The  surface  of  these  dark 
bodies  showed  the  characteristic  granular  ai)])earance  that  we  have 
observed  in  the  degenerated,  though  distincth'  recognizable  tubuli 
found  in  im])lanted  human  testes.  It  is  hardly  probable  that  tis- 
sues so  delicate  as  are  the  liihiili  sciiiiiiifcri,  woidd  endure,  if  dead, 
and  show  as  ])lainl\-  as  thev  do  in  b'ig.  17  (see  also  Figs.  14  and  16) 
at  the  end  of  seventx -live  days  after  implantation  in  an  alien  bed. 
To  believe  this,  one  must  underrate  the  "digestive"  or  "assimilative" 

-  296  — 


SI'.X    (;i,.\.\l)    IM  I'LAXTATIOX 

cap.'icit}-  of  the  iioniial  tissues  ot'  the  ini])l;intati()ii  1)C(1,  and  over- 
rate tlie   resistance  of  those  tissues  to  <lea(l  matter. 

The  forei^oin^'  resuUs  of  experimental  testicular  im])lantations 
n])on  fowls  are  systematically  corrohorative  of  those  ohserved  in 
our  imi)lantations  tii)on  human  suhjects.  i'o  eni])hasi/.L'  the  histolo,H'ic 
restilts  ohtained  in  the  latter,  as  shown  in  the  author's  \arious  ar- 
ticles, and  to  sii])])lement  the  illustrative  drawings  ])resented  therein, 
there  are  shown  herewith  a  series  of  ])hotomicroL;ra])h>  which  show 
even  more  satistactoriK'  the  chanj^es  occurring  in  im])lanted  luunan 
glands. 

The  im])lanted  and  removed  gland  herein  submitted  to  histologic 
study,  is  the  one  alreadv  recorded  of  a  testicle  im])lante(l  up(jn  a 
woman  of  sixt_\'  _\ears  and  removed  over   fom-  months  later.* 

The  illustration  (  iMg.  16),  comprising  an  area  of  the  same  sec- 
tion of  the  im])lanted  testis — a  little  larger  than  that  shown  in 
Fig.  1  .^ — heautifull)-  shows  the  various  strata  from  the  ])eri])hery  to 
the  centre  of  the  gland.  It  shows  with  es])ecial  distinctness  the  ottt- 
lines  of  the  obsolete  liihiili  sciitiiilfcri,  which  have  been  replaced  by 
the  interstitial   coimective  tissue. 

The  foregoing  illustration  wc)uld  seem  to  show  ])retty  con- 
clusix'el}-  that,  while  the  tiihiili  sciiiiiiifcri  of  im])lante(l  glands  un- 
doubtedl}-  Icjse  their  ftinction,  coincidentallv  with  the  death  of  their 
secretor_\-  ei)ithelium — which  ])robablv  inevitably  occurs  in  imi)lan- 
tations  such  as  the  attthor"s — the  mass  ])ro])er  of  the  Itibular  struc- 
ture— /.  ('.,  the  basement  membrane  and  its  i)r()toi)lasmic  content — 
may  survive  for  a  prolonged  ])eriod.  Whether  or  not  anastomosis — 
prfn-iding  a  successful  technic  ever  is  elaborated — will  ])reserve,  or, 
if  it  be  not  \\holl_\-  destroyed,  regenerate  the  generative  gland  epithe- 
lium,  is  ver_\-  doubtful,  although,   ])erha])s,  not   imiiossible. 

The  resemblance  of  the  structtu'c  shown  in  b'ig.  18  to  that 
shown  in  Fig.  8  is  interesting,  more  especialK'  as  the  latter  shows 
a  section  trom  the  e])idi<l\inis  of  the  ram.  It  demonstrates  clearly 
the  com])osition  of  the  dark  strata  of  connecti\-e  tissue  shown  in  the 
variotis  sections. 

It  was  the  aitthor's  good  fortune  receiuK'  to  studv  a  specimen 
ot  a  testis  removed  \-erv  earl\'  after  an  im])lantation.  v^ections  pre- 
pared  from   this   s])ecimen   show   some   interesting   featttres,   as  also 


New    Vnrk   .Medical   .Iijui'iial,    Octoln-r  :!  I ,    IHM.      Case  Vt   of  my   .scrii 

—   297   — 


I  A 1 1.'(  )TKXCJ<:    AX  I )    STJvR  1  ]  JT  Y 

does  the  history  of  the  experiment,  which  later  will  be  presented  in 
detail  in  this  volume. 

Both  testes  were  secured  from  a  powerful  and  apparently 
healthy  man  twenty-three  years  old,  a  professional  athlete,  dead  ten 
hours  of  narcotic  poisoning".  The  cause  of  death  is  worthy  of  note, 
inasumch  as  the  results  of  the  subsecjuent  implantation  of  the  glands 
conclusively  jiroves  that  death  from  narcotic  ])oisoning  does  not  im- 
pair the  vitality  of  im])lantati()n  material.  ( )bviously,  this  greatly 
enlarges  the  field  of  available  material,  and  consequently  the  useful- 
ness of  sex  gland  implantation  as  a  therapeutic  resource.     Kx]:)eri- 


l'"ig.  ]0. — Scfliiiii  (.f  iiiipliiiilrcl  Ic.-lis  fniiii  :i  dininr  dead  leu  liours  of  imreolic  poisoniiis  ]■(■- 
moved  on  tlic  iiinlh  d,,\-.  A-li-C,  dcu'cncridod  rciiuiiiis  of  j-pcrnuitic  tubidi.  1),  interstitial 
(iiitei-Udj'.dar)    coniiei-liNe    tissue    eell    iiiolifcralic^n    and    leucocytic    infilti'ation. 

mentation  at  some  future  time  with  material  from  bodies  dead  of 
carbolic  acid,  bichloride  of  mercury,  and  illuminating  gas  poisoning 
might  be  interesting. 

bUeven  liours  later,  both  testes  were  im])lanted  on  a  voung  man 
of  twenty-two  }ears.  suffering  from  dementia  ])r;ecox.  The  full 
details  of  this  case  will  be  ]U"esented  later.  Nutrition  of  the  sub- 
ject was  oiiI\-  fair.  ( )ne  gland,  the  right,  was  im])lanted  in  the 
su[)rapubic-  region,  l)eneath  the  deep  laxer  of  the  sui)erlicial  fascia 
U])on  the  liiiea  alba.  Tlie  other,  and  the  smaller,  gland,  was  im- 
])lanted  in  the  scrotal   sac,  just  above  the  recipient's  left  testicle. 

—  298  -- 


SI'.X    r.r,ANl)    l.\IIM,AXTAT[ON 

licaliit^t;'  ai)])ar(Mill\-  was  ])tTlfcl  in  bolh  iinplanlations,  1)iit  on 
l!u'  niiuh  (la\-  pus  a])pcarc'(l  in  the  lu'po^aslric  wound,  with  a  dis- 
tincllx'  putrescent  odor.  Pjclicxini;'  tlic  gland  to  1)0  necrotic  and  the 
iin])lantation  conse(pientl\-  a  failure,  we  reniox'ed  it.  To  our  astonish- 
ment we  found  the  tunica  of  the  f^land  adherent  to  the  tissues  of 
the  ini])lantation  l)ed,  and  covered  with  numerous  areas  of  new 
hlood  \'esse]s.  The  centre  of  the  gland  was  necro>ed.  l)ut  a  good 
])ortion  of  the  i)eripher\-  a])])arentl\'  still  was  lix'ing.  The  fate  of 
tlu'  gland  implanted  in  the  scrotum  will  l)e  ])resented  later,  it  I)eing 


♦   *,, 


9'-W^  m    #    '■—It...  %>       ^NP 


•■#■  -C^  ^ 


mm 


Ki-.  :.'(!.-  ,S(cih.ii  of  imiicu  ;ill)U.i;iiira  of  iin| ihiiilni  tcsIN  fioin  lUmnv  dead  of  narcotic  ]ioisoiiiiif;, 
rciiKjvcd  oil  Ihc  iiiiitli  (la,\  after  iiiiphiiilaUon.  'J'lic  section  shown  is  frt)ni  the  inferior 
surface  of  (he  iiiiiiea,  /,  ,..  in  Ihe  zone  of  I'oniael  with  llie  hiiiicii  r<ixi-iihis,i.  'l'hi>  si'clion 
shows  an  alanidanee  of  proliahly  reucnei'al  int;'  or  reiieiierateil  connective  tissue  ci'lls  of 
a  iiceuliar  type  anil  a  inoderale  niniiher  of  leucoc\tc>-.  The  nuclei  in  tlic  specimen  scenie<l 
in  some  iii-i|ance<  lo  iiidicale  a  rcucncral  ion  of  ilie  peculiar  connective  tis-iuc  cells,  .some 
of  which  rescnilde  the  (  hara(  i  eri^l  ic  interstilial  cells  of  llie  intertnbular  areas  shown  in 
till'  preccdinu-  i  lln-l  rat  ions.  In  the  centre  of  the  section  is  a  ])lootl  \cssel  of  apiiarcnUv 
new    formation,    containini;'   normal    Mood. 


sutlicient  at  this  ])oiiit  to  ])resent   the  liistologic   features  of  the  re- 
inoN'ed  companion  testis   (  I'ig.  I'M. 

.\lthough  not  so  i)lainl\-  marked  as  in  the  section  shown  in 
h'ig.  21,  the  earl\-  ])roIi  feration  of  the  inlertiihnlar  tissue  seemingly 
is  tpiite  evident  in  JMg.  1''.  The  interior  of  the  testis  being  necrotic 
and  infected,  it  is,  of  course,  doubtful  whether  in  this  particular 
instance  permanent  organization  of  this  particular  area  would  have 

—  299  — 


T.MPOTRNCE   AND    STERILITY 

occurred,   althoii<^"h   the   author  believes   that   it   quite   Hkely   would 
have  done  so. 

A  most  interestint;'  feature  of  the  various  sections  of  the  im- 
planted testicle  examined  was  the  presence  of  a  considerable  pro- 
portion of  normal  blood  still  remaining  in  the  old  vessels,  in  con- 
nection with  cor])uscles  which  were  undergoing  dissolution.  There 
also  were  many  extravasations  or  infiltrations  of  normal  blood  in 
the  tissues,  inters])ersed  with  both  new  and  old  ca])illaries.  This 
suggests  that  the  vitality  of  the  im])]ante(l  gland  is  (|uite  enduring. 
sufficientl\-   so  to  gi\'e  i)lent\-  ot    time   for  its  nourishment  from  its 


Fi^-.  2}.  ScctiDii  of  interior  surf.icc  of  tunica  alliimiiu'a  of  iiiii)laiit(Ml  testis  from  donor  dead 
of  iiareovie  poisoiiiiin',  reinoxed  on  the  ninth  ila.\-.  \,  a|>iiarently  new  blood  vessels  eon- 
tainina-  normal  blood.  15.  area  ot  )ieeuli.ii-  eelj^.  iinbaldy  derived  from  the  interstitial 
Cintertiibnlar)  tissue.  'Phis  seetion  shows  ilie  ordinarx^  eiiaraeteristics  of  the  connective 
tissue    of    tlie    liitiirii    iiiiiprl ii    of    file    teslis.    with    numerous    leueocytes. 


new  environment  to  begin.  Reflecting  on  Leo  J^oeb's  ex])eriments 
in  cultivating  tissue  cells,  both  /;;  7'n'o  and  /';;  I'iiro,  and  the  en- 
durance of  life  in  frozen  cells,  it  should  not  be  surprising  that  a 
healtln-.  sterile  gland,  bathed  in  nourishing  blood  and  tissue  juices 
at  the  normal  tem])erature  of  the  bo(l\-,  should  survive  and  eveiUual- 
ly    lorm   a   new   \-ascular   supjtlw 

The  somewhat  e.\traordinar\-  a])pearance  of  the  immediately 
lorcgoing  section  (  I'ig.  21  ) — which  strongly  resembles  a  neoplasiuic 
growth — ptjssibl}'    ma\-    be    explained   as    follows;     In    the   author's 

—  300  — 


f) 


SF.X    r.T.AXI)    T.Xrrr.AXTATTON 

tcclmic  of  implantation  small  areas  of  the  liiiiica  alhi((/inca  arc  ex- 
pected. At  the  ])oint  shown  in  the  illustration,  the  area  of  the 
exscction  did  not  in\-olve  (pn'tc  the  entire  thicl-;ness  of  the  tunica 
throughout,  hut  at  one  point  was  left  an  extrcmcK'  small  aperttu"e 
throus.j"h  which  the  rapidl}'  ])roli  ferating-  interstitial  cells  extruded. 
The  area  ma_\",  of  course,  re])resent  a  se\ered  1)li)od  vessel,  througli 
which  the  cells  are  extruding-  from  heneath.  We  have  noted  in  other 
sections  an  invasion  of  the  cortex  hy  interstitial  cells  at  jjoints  of 
denudation. 

In  presenting  tlie  various  st'ctions  illustrative  of  the  histology 
f  im|)lanted  testes,  the  author  is  not  unmindful  of  ])()ssil)le 
sources  of  error,  which  suhse(pientl\-  ma\-  he  corrected  either  h\' 
himself  or  other  investigators.  At  ])resent  writing,  however,  the 
results  seem  to  he  conclusive.  The  ])eculiar  t}'pe  of  connective  tis- 
sue shown  in  the  \-arious  sections  nmst  either  he  the  interstitial  cell 
of  r.ex'dig— or  a  derixative  of  it — or  there  exists  in  the  testis  a 
delinite  t_\])e  of  tissue  hitherto  undescrihed.  It  is  hardly  i)ossil)le 
that  the  tissue  demonstrated  herewith  could  have  been  overlooked 
])\-  the  man\-  com])etent  histologists  who  have  studied  the  normal 
tissue  regeneration  in  the  testis  are  four:  1.  The  true  secretor_\- 
The  leucocxte  theorv  of  connective  tissue  generation  of  Cohnheim 
and  MetchnikolT  ha\ing  heen  abandoned,  the  i)()ssil)le  sources  of 
tissue  regeneration  in  the  testis  are  four:  1.  The  true  secretory 
e])ithelium:  2,  the  Sertoli  cells;  3,  the  ordinary  lihroconnective  tis- 
sue of  the  gland  se])ta  and  the  tunica  alhuginea  :  4,  the  interstitial 
connective  tissue  or  "between  cells""  of  Leydig'.  The  e])ithelial  cells 
max  he  ruled  out,  ofThand.  The  v'^ertoli  cells  are,  in  our  oi)inion,  of 
even  less  importance.  The_\'  lie  within  the  tubuli  and  have  a  purely 
lutritixe  function,  concerning  the  true  secretory  epitheliimi,  and 
die  when  the  latter  dies.  The  ordinary  flbroconnective  tissue  ])lays 
but  a  minor  part.  The  microsco])ic  sections  ])resente(l  in  this  volume 
])lainl}-  show  the  strata  of  the  histologic  elements  and  emphasize  the 
dilTt'rence  in  the  structure  of  the  various  strata. 

The  interstitial  cells  ff)un(l  in  the  normal  ram's  testicle  and 
those  shown  in  the  section  from  an  implante(l  lowTs  testis  are  (|uite 
>imilar  throughout.  It  is  not  to  be  expected  that  the  cells  in 
regenerated  implanted  glands  alwa_\s  will  apjjcar  the  same.  That 
icctions  of  implanted  glands  or,  for  that  matter,  of  normal  glands, 

—  301   — 


TMPOTl^NCl':   AND    STJ-.RTIJTY 

will  show  the  "idealized"  classic  confoniiatioii  and  arrangement 
shown  in  certain  works  on  histology  also  is  not  to  he  expected.  The 
cells  are  thicker  than  normal  and  more  or  less  altered  in  form  and 
grouping",  hy  contraction  of  the  mass  and  resulting  pressure,  l)oth 
hy  their  own  organization  and  a  certain  amount  of  ordinary  iihro- 
connective  tissue. 

Like  all  other  connective  tissue,  the  interstitial  tissue  of  the 
testis  "consolidates  and  contracts,"  hut  it  holds  its  own  in  respect 
of  vitality,  and  a  very  small  nodule  of  the  im])lanted-tissue-end- 
result.  prol)a1)ly  contains  as  many,  jjossihly  more,  of  the  Le_\dig  cells 
than  does  the  entire  organ  at  the  time  of  implantation.  That  these 
cells  arc  as  active,  or  their  hormone  i)roduct  as  ahundant  and  physi- 
ologically as  ])otential,  as  are  the  internal  secretory  cells  under 
normal  gland  conditions,  is  open  to  question.  I'ossihly  the  relative 
increase  in  the  quantity  of  the  highly  s])ecialized  cells  in  the  im- 
])lanted  gland,  with  a  consequent  relatively  greater  amotuit  of  hor- 
mone produced,  mav  comj^ensate  for  a  dilTercnce  in  the  quality  of 
hormone  production.  That  the  implanted  cells  are  therapeutically 
effective  is  no  longer  an  open  {[uestion  in  the  author's  mind.  The 
chief  ])rol)lem  now  is:  Will  the  imjilanted  gland  in  elderly  subjects 
eventually  functionally  succumh  to  the  recipient's  tissue  influence 
and  ])ro(luce  a  (piantitv  and  (|uality  of  hormone  normal  to  his  or 
her  age?     Possihl)-;  we  have,  however,  two   factors  to  consider: 

1.  The  rejuvenation  of  the  entire  hod}-  hy  the  alien  hormone, 
a  rejuvenation  in  the  beneht  of  which  the  implanted  tissue  itself 
participates. 

2.  h'ven  granting  that  the  ([uality  and  ((uantity  of  the  honuone 
l)roduce(l  hy  the  implanted  tissue  eventualh'  is  not  comparahle  to 
that  produced  hy  a  similar  number  of  cells  under  normal  conditions, 
the  sum  total  of  hormone  ])ro(luction  of  the  implanted  tissue  and 
the  subject's  own  glands  necessaril\-  is  grep.ter  than  normal  to  the 
subject's  ;ige. 

It  is  prol)a])le  that  a  gland  from  an  older  donor,  implanted  on 
a  \oung  subject,  ma\-  be  rejuxeiiated  b\-  the  im])lantation.  In  gen- 
eral, such  im])laiUati()ns  ai'c  more  logical  than  the  imi)l;mtation  ot' 
\ei'y    maluix-    glands    upon    older    I'ei-ipients. 

In  all  ol  Iii.x  implantation  woi'k  the  author  has  been  in)])ressed 
with   the   tact   that   the  liiiiiai  (ilhiKjinea  and  the  gland  tissues  just 

—  3()J  — 


Sl-'.X    Cl.AXI)    IMI'I.AXTATIOX 

l)enc';illi  il  sliduld  l)c  tlu'  iiio>l  \alu;il)lc  of  the  U'--ticii!;n"  tissues  wIutc 
])artial  iiii])lantati()iis  arc  (loiu'.  iikt(.'1\  l)t.'c-au>c  l)ftti,'r  iKiurished  and 
llicrcforf  inostK'  lil<cl\'  to  sur\i\a',  w  itli  resulting'  i"ai)id  and  cxtcnsiN'c 
rci^eneration  ot'  the  interstitial   tissue  l)eneath   llie   ttuiica. 

Ca-i;.*  The  case  in  wliicli  wa-  implanted  tlic  lesti-  fmni  which  the 
sections  sliown  in  J'i.tis.  19.  20  and  21  were  taken  w as  as  f(.)ll(jws :  Yonns^' 
man,  at^ed  tw'ent\--two  ^x-ars.  no  occupation.  lieredit\'  harl,  paternal  t^rand- 
I'atlier  and  one  paternal  annt  committed  snicide.  Another  paternal  aunt  had 
scwen  cliildren.  l'i\'e  of  whom  developed  dementia  between  tlie  a,i;es  of  six- 
teen and  twenty  years.  This  aunt  was  insane  for  twenty  years  after  the 
hirth  of  her  last  child  and  died  insane.  I'atient  was  very  hrit^ht  at  school. 
He  suffered  with  a  head  injiu'y  of  some  kind  foiu"  years  a.t^o.  whicli  his 
parents  are  inclined  to  helie\e  had  something  to  do  with  liis  condition,  as 
their  attention  was  tirst  attracted  to  liis  mental  state  not  long  afterward. 
I'or  some  time  he  com])Iained  of  headache.  Tliis  injin'\'.  in  our  o])inion.  bore 
only  a  coincidental  relation  to  the  mental  state  that  subse(|uentl\'  de\'eloi)ed. 
Taking  into  consideration  the  family  histor_\'  inid  the  typic  nature  of  tiic 
c;i-e.  and  tlie  absence  of  hi--t'iry  of  really  se\ere  trauma  and  of  jire-ent  e\  i- 
deiice-  ui  pre\  ious  trauma.  m_\-  positinn  reg.arding  the  possible  etiologic 
relation  of  the  h.ead  injury  to  the  mental  state  would  seem  to  be  justiiied. 
About  three  Acars  before  I  saw  tlie  case,  a  Xeisserian  infection  was  con- 
tracted. Reco\  cry  a])ijarenil>'  was  satisfactory.  'J'he  contraction  of  this  in- 
fection. acc(jrding  to  his  mother,  "preyed  upon  his  mind  a  good  deal  and  may 
ha\e  had  something  to  d(j  with  his  mental  condition." 

Something  over  three  years  before  the  author  first  saw  the  patient, 
mental  s\'m])toms  began  to  l)e  noticeable.  Dr.  Archibald  Church  was  con- 
sulted.   September    13.   1914.      His   report    in    brief    was   as    follows: 

"The  case  impresses  me  as  Ijeing  the  initial  phase  of  a  dementia  pr;eco.\. 
I  anticipate  that  he  will  develop  a  phase  of  activity,  perhaps  with  a  good 
fleal  of  excitement  and  boisterous  conduct,  or  he  may  become  more  and  more 
stupid  and  catatonic.  At  any  rate  it  will  be  some  time  before  he  is  better 
and  Ids  ultimate  ])r(.>si)ects  are  extremely  bad." 

Soon  after  the  case  was  brought  t(j  <jur  attention,  we  referred  it  to 
Dr.   llay.'ird  Holmes   for  an  Alxlerlialden  test,     ilis  repori   was  as  follow>  : 

"The  hemogb^bin  was  80  per  cent,  the  whites  12,400.  the  reds  4.800,000. 
the  polymorphonuclear  neiUrophiles  57  ])er  cent,  small  lymplKxwtes  30  per 
cent,  large  lymphocytes  8  per  cent,  transitionals  1  per  cetit.  and  eosinophiles 
4  per  cent.  Th.e  form  and  character  of  the  red  corpuscles  were  normal  and 
no  ])arasites  were  to  be  observed. 

Tlie  serum  of  this  blood  was  centrifugated  for  two  and  a  half  hours 
and  1..T  c.  c.  of  the  strum  was  placed  in  each  of  six  dialyzers,  in  whicli  was 
also  ])laced  one  gram  of  the  following:  Hmnan  organ  albinnins  prepared 
according  to  the  method  of  .Miderlialden  ;uid  each  tested   iree  from  ninhydrin 

*  'i'lii.s   ca.se   \v:(.-;   r.-jKirOMl    in    tli...    X.    Y.    Medical    ,1(H1|-iim1.    Ai.ril    :;.    T.O  ."i. 

-  -    30.3    — 


]:\I1'()T1',.\C1<:    AND    STJ'.RIIJTY 

rcduciii.^  i.-k-nR'iit>  lirl'ore  hciiig  used,  nanicK-  against  cci"c'1)ral  cortex,  pancreas, 
tlijroicl,  ovary,  testicle,  and  one  control.  The\-  were  incnbated  in  Hrlennieyer 
flasks  each  containing-  20  c.  c.  of  sterile  water  for  a  period  of  sixteen  hours 
at  a  temperature  of  90°  to  100°  V.  At  the  end  of  that  time  they  were  each 
tested  against  the  ninhydrin  solution  and  boiled  for  one  minute.  Every  tube 
proved  negative,  being  perfectly  clear  at  the  end  of  a  half  hour. 

The  blood  serum  in  this  case  does  not  give  any  of  the  reactions  of  de- 
mentia ])r;ec()x.  Neither  does  the  blood  picture  of  the  microscopical  exam- 
ination correspond  with  the  blood  ])icture  in  cases  of  deiuentia  prsecox.  Al- 
though 1  made  no  considerable  examination,  the  ocular  reflexes  and  the 
mental  picture  did  not  suggest  to  me  even  the  possibility  of  an  embryonic 
case  of  that  disease.  I  do  not  hesitate  to  state  that  this  is  not  a  case  of  de- 
mentia  prjecox." 

Dr.  lloliiK's'  re])ort,  taken  in  cointection  with  Dr.  Clnnxli's 
diagnosis  and  the  anthor's  own.  which  corroborates  that  of  Dr. 
Chtirch.  is  wortliy  of  seriotts  reflection.  That  the  subject  was  in- 
sane is  l)e_\()n(l  the  ])ossil)ility  of  doubt.  With  (hie  deference  to 
Dr.  lioliues"  ()])ini()n,  that  the  case  must  be  classed  as  dementia 
pr;ecox  is  olniotts.  The  prevailins^'  nomenclature  of  psychoses 
is  faulty,  it  is  true,  and,  in  the  case  of  dementia  pnecox,  absurd, 
in  a  \\a_\',  the  term  havino-  only  a  syiuiJtomatic-chronoloL^ic 
basis,  with  no  definite  pathologic  foundation,  btit  at  jjresent  it 
is  the  best  noiuenclature  available.  it  is  ])()ssible  that  the 
Abderlialden  test  and  heiuologic  observations  eventually  may 
enable  us  to  resolve  dementia  prjecox  into  several  distinct  path- 
ologic t\])es.  one  of  which  responds  ])ositively  to  the  .Vbderhalden 
test,  while  the  others  do  not.  This  would  facilitate  a  more  scientific 
nomenclature  and  classification.  It  of  course  is  ])ossil)le  that  our 
conchision  regarditig  the  head  injury  in  the  case  is  incorrect,  if  so, 
this  nattirall}-  luight  ex])lain  the  negative  Abderlialden.  Even 
granting,  h()\ve\-er.  that  the  head  injury  was  an  exciting  etiologic 
factor,  the  same  nomenclatttre  wottld  confront  tis. 

The  evidences  of  mental  deterioration  in  the  case  in  ])oint  are 
distinct,  and  of  a  character  which  lead  me  to  classify  the  psychosis 
as  hebephrenia  of  the  ])aranoid  ty])e.  J  lallucinations  have  been  a 
doiuinant  feat  tire.  X'oices  whis])ering  adverse  comments  and  in- 
sidts  were  (lail\-  com])lained  of.  Lack  of  energy,  and  the  com])laint 
that  he  was  too  weak  to  work,  were  salient  ])()ints.  'J'he  most 
prominent  feature  of  tlie  c.ase  was  the  ])alienl's  notion  that  he  was 
a   great    architect    and   btiilder.      I  lis   ])articular   obsession    was   that 

--  3(14  -- 


SI-:X    (U.Wl)    IMri.AXTATlOX 

he  was  ill  the  eniplox'  of  tlie  city  (it  Cliicai^o,  his  s])ecial  l)usiness 
Ix-ini^'  tlie  rein()(lelhii,<4-  of  e\-er_\-  lar^e  l)iiil(h'n,!4"  witliin  tlie  loo]).  lie 
S])ent  nianv  lioiirs  eacli  (hi\-  in  writiiii,^  "s])ecitications"  for  such 
rcniodeliiiL;'.     'I'lie  following;  are  ^ani])Ies  of  liis  hicuhration>  : 


Fiir.  ■2'2. — Ti-sii^  fi'ciin  a  lin(l\-  diiid  icii  liom'-  ivoiw  cncaiiic  [•ni^niiini;',  iiiii>lant(.'<l  in  a  ea<o  of 
(li'iiii'ijlia  pr:i'C'j\.  liiijilaiilali'iii  cli  \fii  limii-s  lain-  lw,-mv-i.iic  laMirs  atlt-r  death.  Draw- 
iiiir  made  six  wi  iks  alter  llie  iiii|ilaiilatioii.  l-'our  iiionlli<  after  tlie  iuiplaiitati^iii.  tlie 
iiii|damed   testi-   was   a    tinii.   eliaraeti  ri-tieall\'    -liaped   ImhIv   almut    l\vethinl<   i>i   n<   'iri.u'iiial 


1.  Tlie  Afallcrs  Buildinji-  was  built  as  large  in  City  as  neither  Building 
contribute  to  Herbert  at  all.  l-'ino  stones  un  Mailers  Building  has  stones  rep- 
resenting the  ends  of  eartb.  (Jne  on  each  side  of  door  as  two  poles  or  ends 
of  earth.  Have  building  largest  in  world  and  fme  stones  as  Equator  higher 
up  as  students  dont  know.      Have  lights  sbowing  these  stones. 

—  305  — 


I.MPOTKN'CJ-:   AXi:)    STJvRILlTY 

2.  The  Hub  stuie  built  before  Alar  shall  Field  &  Company  Building. 
Both  sell  men's  suits.  Buildings  has  no  opposition  on  Account  of  neither 
seeing  each  other.  Mostly  for  two  hotels  or  Theatres.  Blackstone  and 
LaSalle  Hotel,  leaving  both  tops  off  both  hotels  and  they  will  be  eighteen  or 
Blackstone  Theatre  and  Majestic  Theatre,  Blackstone  takes  one  off  of  Ma- 
jestic leaving  Eighteen.  4  Building  and  4  stories  make  same  as  largest  Printer 
Building.     Both  see  Monadnock  Bldg. 

3.  The  LaSalle  Hotel  built  after  ]\IcCormick  Bldg  only  a  Hotel.  Built 
same  distance  from  Railroad  and  McCormick  Bldg.  and  not  hurting  T.  C. 
R.  R.  Have  large  smoke  stack  running  up  side  of  Hotel  for  no  interruption 
of  I.  C.  smoke  stacks.  Built  also  on  account  of  Taft.  Same  height  as  Mc- 
Cormick.  Top  of  Seats  are  higher  in  LaSalle  Hotel  on  accounts  of  foreign 
countries  and  Washington  and  also  Quaker  City  Church.  People  must  not 
think  they  are  Queen  and  Kings  Seats  here  on  that  account.  Little  like 
Blackstone  on  Top   of  Build,  onlj'  larger  and   different  altogether. 

4.  The  Franklin  I'ldg.  is  the  building  supposed  to  be  finest  printers 
building  in  city  to  honor  Bctijaiiiiii  I'ranL'lin  the  same  man  discovered  tele- 
phony. Same  can  be  used  as  business  building  as  close  to  Heisen  Bldg.  as 
Heisen  Bldg.  built  for  high  telegraphy  today,  bringing  telephony  and  tele- 
graph together  on  account  of  printing  paper  being  very  precious,  and  two 
fastest  ways  of  protecting  same.  Offices  to  be  used  as  same  making  Frank- 
lin Bldg.     lunest  in  city. 

()cto1:)er  3,  1914,  by  reqttest  of  the  ])titient's  mother  and  with 
complete  nnderstancHng  on  her  part  of  the  experimental  nattire  of 
the  procedtire,  the  atithor  implanted  two  testes  upon  the  patient,  one 
in  the  suprapubic  region  and  the  other  in  the  left  side  of  the  scrotum. 
The  resuk  of  the  suprapuljic  implantation  ah-eady  has  been  rehited. 
In  passing,  it  may  be  stated  that  faitUy  technic  i)robably  was  respon- 
sible for  the  loss  of  this  testicle.  The  gland  was  very  large  and  firm 
and  the  implantation  bed  was  hardly  ample  enottgh,  the  resulting 
pressure  being  disastrous,  liven  as  matters  were,  a  considerable 
portion  of  the  gland  was  living,  adherent,  and,  had  it  not  been  re- 
moved, possibly  would  have  survived  for  some  months. 

The  scrotal  implantation  was  ])erfectly  successful.  Fig.  22 
shows  the  condition  at  the  end  of  the  sixth  week  ( .\  ).  December  16, 
1914,  there  had  been  no  diminution  in  the  size  of  the  im])lantation 
mass  that  could  not  ])e  ex])1aincd  ])y  resolution  of  the  defensive  exu- 
date sttrrotinding  it. 

Begimiing  abotit  one  week  after  the  implantation,  considerable 
im])rovement  in  the  i)atient's  mental  condition  was  noticeable.  His 
"architectural"  writing  became  a  little  more  coherent,  and  he  would 
not  write  luiless  urged  to  do  so.     He  was  encotu'aged  to  correspond 

—  306  ^ 


vSEX    GLAXn    T^[^^<AXTATIOX 

with  liis  friends.  C'omparison  of  a  letter  written  1)\-  liini  soon  after 
the  implantation  Avith  another  written  later,  showed  a  marked  im- 
provement.    'J'his  latter  missive  is  herewith  snhmitted  : 

^liss , 

G HldR., 

Dear  Miss , 

I  received  your  flowers  and  was  ,ulad  to  know  sonic  kind  friend  rc- 
nicnd)crcd  mc.  Tlie  tlowcrs  were  bcautilul  and  my  mother  was  down  t(j  set: 
you  as  she  said.  Xow  _\-ou  know  I  am  licrc.  Will  want  to  sec  you  next  time 
I  get  a  chance  mysel  f . 

Your   friend. 


ObviotisK'.  the  improvement  mav  ha\'e  been  of  no  si)eeial  sig- 
niticance,  althoui^h  it  was  stiftieient  to  aronse  i^'reat  enthusiasm  on 
the  part  of  his  relatives  and  friends. 

'['he  improvement  eontintied  for  several  weeks,  during  wdiieh 
time  the  patient  did  not  do  an\-  writing,  lie  began  reading  assichi- 
ously,  cxjM'essed  a  desire  to  "g(j  to  work."  and  showed  interest  in 
many  matters  to  whieh  he  hitherto  was  indifferent.  This  state  of 
affairs  lasted  for  several  weeks,  during  whieh  time  his  response  to 
various  tests  showed  a  marked  ehange  for  the  better.  Tlic  as])eet 
of  the  ease  now  again  ehanged  and  the  mental  eondition  was  as  bad 
as  ever.  1  le  now  sho\ved  some  irascil)ilit\-  and  resumed  his  writing. 
Several  weeks  later,  he  again  improved  and  after  a  few  weeks  was 
distinetl)"  l)etter.  1  le  had  eeased  writing,  seldom  heard  voices,  and 
was  working  in  a  drug  store  for  a  jiortion  of  the  da}'.  ( )n  question- 
ing he  admitted  the  "■fiiolishness'"  of  his  literary  effusions  and  hallu- 
cinations. l)tU  if  these  matter>  were  discussed  at  length  his  ex]ires- 
sions  still  were  unsoimd.  althoitgh  not  so  markedly  as  former!}-. 
There  was  a  change  in  the  as])ect  of  the  case  in  that  there  now  was  a 
tendenc}'  to  melancholv  and.  as  a  s])ecial  source  of  worr\-.  an  imagi- 
nar}  detect  of  eyesight,  which  had  been  careful!}-  tested  and  ])ro- 
nounced  normal  ])\-  Dr.  I  larr\-  (".radle.  There  also  was  a  new  delu- 
sion, lie  attributed  the  ■"luni])""  in  his  ^crotum  to  a  large  marble 
which  he  had  swallowed  when  a  bii\. 

November  3.  ]*'14.  Dr.  I\ali)h  Webster  re])orte<l  a  blood  exam- 
ination as  follo\\-s  : 

—  3117  — 


IMPOTENCE   AND    STERILITY 

Red  cells    5,050,000  per  c.  mm. 

White  cells    16,400  per  c.  mm. 

Polymorphonuclear   neutrophiles    85% 

Polymorphonuclear  eosinophiles    2% 

Polymorphonuclear  hasophiles   1% 

Large  mononuclears    1% 

Small  mononuclears    lll% 

Myeocytes 0% 

Transitional   0% 

Hemoglobin    . 88% 

Color  index   8 

Coagulation  time 

Nucleated   red   cells Negative 

Polychromatophilia    Negative 

Degenerations     Negative 

Blood  pressure    (systolic  ) 120  mm. 

Comparison  of  Dr.  Webster's  reports  with  that  of  Dr.  Holmes 
is  sttggestive,  altliottgh  l)y  no  means  conckisive.  The  improvement 
in  hemoglobin  and  the  ntimber  of  reds  is,  however,  consistent  with 
what  we  have  observed  in  previotis  implantation  experiments. 

Febrtiary  8,  l'U5,  the  patient  was  snrprisingly  improved  both 
as  to  mentality  and  general  condition.  The  "melancholy"  had  dis- 
appeared and  his  mother  reported  that  he  was  qttite  industriotts 
and  ambitions. 

About  December  15.  1^)16,  the  ])atient  re]:)orted  and  was  found 
to  1)e  still  more  improved  mentally.  His  general  health,  however, 
seemed  to  be  failing,  without  any  especial  reason  therefor.  Quite 
recently  the  author  was  informed  that  the  patient  had  developed 
tuberculosis.     There  has  been  no  opportunity  of  verifying  this. 

It  will  be  evident  from  the  foregoing  account  of  this  case  that 
the  author  by  no  means  is  claiming  indisputable  therapeutic  results 
from  the  implantation,  'i'herc  nevertheless  is  al)undant  encourage- 
ment for  further  ex]:)erimental  work  in  dementia  pra^cox.  The  case 
may  still  further  improve,  and  in  any  event  it  may  later  be  shown 
that  there  is  a  form  of  dementia  ])nccox  which,  if  taken  early,  is 
susce])tible  of  im])rovement.  or  jiossibly  even  ctux\  bv  implantation. 
If  there  is  such  a  form,  it  ])robab]y  will  be  fottnd  to  be  that  which 
shows  a  ])()sitivc  Abderhalden   reaction. 

In  an  article  entitled  "I  letero])lastic  (irafting  of  Testicle,"''' 
Dr.    Robert  T.   Morris  relates  a  case  as   follows: 

*  X.    Y.    .Mvcl.    ,J.)ur.,    .Now    7,    I'.H  1. 


Sl'.X    C-I.AXI)    IMl'I.AXTA'riOX 


(.\\SK.  \\  .  A.  S.,  ai^ccl  I'orly-niiK-  vears.  Tfii  years  iii"cviousl\-.  as  a  rc- 
Milt  of  l)eini;'  tlirciwn  li_\-  a  huckin.y  li(.)rsv-  npdn  the  iMnnnicl  of  a  Alcxioan 
saddle,  liotli  of  ihe  patient's  testicles  had  heen  crushed  and  had  t)een  sul)- 
se(iiientl\'  reino\  ed  1)\"  operation.  SliortI}'  afterward,  all  ciiaracteri'stic  mas- 
culine cenesthesia  was  lost  and  the  patieiU.  a  lar!.;e  strong  man,  hecaiue  ex- 
tremely nei'Nous  with  periods  of  .yi'eal  depression,  sheddint;  tears  at  sli.nht 
pr(i\  I  icatiiin.  .\s  a  man  uf  educaliim  and  int(.'lli,nence  he  C(imi>rehe:ided  the 
entire  shiiation  and  knew  the  reason  for  his  ])s\chic  condition,  althou.nh  he 
said  that  it   was  at  limes  unhearahle. 

On  Consultation  with  the  patient  I  recalled  to  him  (nir  experience  with 
oxarian  .uraftin.n.  After  I  had  jjuhlished  the  desci'i])tion  of  o\arian  .uraftin.u" 
in  189.T  and  had  introduced  the  idea,  a  lar.ue  mimhjr  of  authors  soon  fur- 
nished data  of  their  own  hearing  ui)on  the  suhject.  There  was  a  tiX't"-'''''' 
conclusion  alons^  lines  which  hiolo.uists  mi.iiht  ha\e  anticipated,  lo  the  effect 
that  the  tissues  of  (.)ne  indix  idual  are  amaL;oiiistic  to  the  tissues  of  another 
mdixidual.  Therefore,  helernpla^tic  t>rafts  of  aii\  >'irt  are  comnioiil}-  ali- 
sorhed  pronii)tly  hy  the  ho>t.  The  de.uree  oi  antau-onism  hetween  individuals 
varies  greatly,  and  occasionally  we  ma\'  lind  two  people  (or  other  aniiuals  ) 
which  receive  each  other's  tissues  with  good  grace,  if  a  l:)it  of  levity  luay  he 
pardoned. 

The  ])atient  was  willing  to  take  the  chances  of  ohlaining  benefit  from  a 
grafted  testicle,  and  entered  the  Post-Graduate  Hospital,  l'"el)ruary  4.  1914. 
The  first  ]>atienl  who  otTered  opportunity  for  furnishing  the  graft  had  un- 
descended testicle  and  hernia:  he  agreed  to  allow  me  to  use  a  pari  of  his 
testicle  for  grafting"  purposes.  This  i)atienl.  a  \oung  man  Iweiily-six  years 
of  age.  responded  so  strongly.  ho\ve\er.  to  the  \'on  Pircjuet  test  for  tuher- 
culosis  thai  1  preferred  nol  to  luakc  use  of  his  tissues.  The  next  case  was 
one  of  a  man  fifty-six  \ears  of  age  with  a  \er_\'  large  hernia,  who  made  no 
re-pi)n~e  to  the  \  on  ['ir(|uet  te-t  fur  luherculi  i -i>  nor  to  the  \\':i.-serniann  test 
for  sxphilis  and  who  ga\c  a  record   of  good  general  health. 

.\  wedge  of  tissue  was  taken  from  the  testicle  of  this  patient  and  placed 
in  nonual  saline  solution  uiuil  W.  -\.  S.  could  he  anesthetized  and  ])repare(l. 
The  segment  oi  testicle  was  cut  intu  four  slices  with  a  sharp  razor,  these 
slices  a\eraging  ahout  three  nun.  in  thickness,  and  in  length  approximately 
that  of  the  testicle  from  which  ihcy  had  heen  removed.  One  of  these  seg- 
luents  was  engrafted  in  the  right  scrotum,  another  one  was  placed  beneath 
the  fascial  sheath  of  the  right  rectus  abdominis,  and  the  third  segment  i)laced 
beneatli  the  sheath  of  the  left  rectus  alxlominis.  .A  W'ier's  celluloid  testicle 
was  placed  in  the  left  side  of  the  scrotum  for  the  purpose  of  g"i\ing  to  the 
sympathetic  lu^rves  the  impression  of  a  natural  mass  in  that  \icinil_\-.  The 
wounds  healed  b_\-  primary-  union,  and  in  fort\-eight  hours  from  the  tim.c 
when  the  grafting  was  done,  the  ])atient  slated  that  he  was  distincll\'  con- 
scious of  the  effect  en"  the  internal  secretion  which  he  was  absorl)ing"  from 
the  grafts.  In  fact,  at  thai  time  occurred  the  lirsl  distention  of  the  corpora 
ca\erno-a  and  corpus   sixHigiosuiu  thai  had  not  occurred  in  ten  \ears. 

-  -  309  -- 


IMl'OTJ'.KXI-:    AND    STERTFJTY 

Tlic  su1)se(|iicnl  liislorx-  of  this  case  showed  considerable  tem- 
porary ini])rovenient.  v^iich  l)enelil  as  was  derived  disapi)eared 
after  a  few  months,  as  nn'i^ht  have  been  expected  from  the  fact  that 
the  "wedge"  of  testicle  mnst  have  been  small  and  the  testicle  from 
which  it  was  tal<en  necessarily  (le,i:;enerated  —  to  say  nothing  of  the 
advanced  age  of  the  donor. 

It  has  been  the  anthor's  aim  to  ])resent  the  results  of  his  experi- 
ments as  fnlly  and  im];artially  as  ])ossible.  That  the  resttlts  of  the 
in]plantation  per  sc  are  remarkal)le,  ])robal)ly  will  be  admitted.  The 
patient  for  a  ])eri(xl  of  some  months  indubitably  has  a  third  testicle, 
which  of  necessity  is  living,  and.  inferentially  at  least,  producing 
hormone.  iM'om  his  studies  in  im])lantation  the  author  has  no  doubt 
whatever  that  during  this  time  hormone  production  is  going  on. 
The  (juantitv  of  gland  tissue  still  ])resent  and  the  length  of  time 
since  the  im])lantation  in  all  cases  thus  far,  warrant  the  assumption 
that  sttch  an  implantation  is  certain  to  secure  the  [)hysiologic  and 
therapeutic  effects  of  the  sex  hormone.  Whether  or  not  these  effects 
are  what  we  desire  in  a  given  case  de])ends  u])on  its  character. 
The  same  may  be  said  of  the  i)ermanency  of  the  result.  We  wish 
to  state  that,  although  it  may  be  ])r()ved  that  glands  from  unrelated 
subjects  do  not  show  such  residts  as  seen  in  Ivxperiment  I.K  of  this 
series,  we  still  may  obtain  from  unrelated  glands  results  which  wdll 
])rove  of  immense  value.  The  author's  various  contribtitions  ap- 
])arentl\-  ])rove  this  point.  Then,  loo,  even  though  the  physiologic 
results  obtained  in  fowls  were  very  discouraging — which  they  are 
not — such  results  b}'  no  means  would  settle  the  various  questions 
involved  in  human  im])lantati()ns.  \Miile  achnitting  possible  sources 
of  error,  the  anatonn"c  and  histologic  results  of  the  author's  experi- 
ments in  towls  and  human  beings  ap])ear  to  be  quite  conclusive. 
The  letters  of  the  experimental  alphabet  seem  to  l)e  fairlv  complete. 


—  310 


CHAPTER   Xlll. 


Additional  Clinical  Cases  of  Sex  Gland  Implantation. 


Till-:  author  ])re>eins  liercwitli  l)i-i'ef  rc'])orls  of  six  additional 
cases  of  successful  im])]antations.  lie  will  at  this  time  say  hut  little 
ftu'ther  than  he  alreadv  has  said  re,<4"ardin,<4'  the  physioloy-ic  and 
therapetttic  effect  of  sex  i^iand  ini])lantation.  wStifticc  it  to  state  that 
not  onlv  have  ])reviotis  ohservations  heen  veritled.  httt  there  also  have 
been  noted  certain  a])parent  results  which  still  further  contirni  the 
aiuhor's  belief  that  in  the  sex  ^iand  JKjrmone  we  have  the  most 
]io\verftd  cell  stinudant.  nutrient  and  re.^'enerattjr  at  ])resent  available 
to  medical  science.  At  ])resent  writin<^  the  additional  evidence  is 
stich  that  the  facts  seemin,i^i_\-  are  estaiilisliecl  on  a  reasonabl)'  firm 
basis,  free  from  sus])ici()n  of  coincidence  or  intercurrent  factors. 
-Vote  in  this  connection  the  cases  of  double  te-^ticttlar  imi)lantations 
herein  reported.  These  case>  a])])arentl_\-  are  conclusi\-e.  I'nder 
pro]jer  conditi(jns  failure  shotdd  Ijc  rare  and  the  resttlts  are  nnt  likely 
to  be  disappointing. 

Case  1. — This  is  by  far  the  most  re- 
iiiarkai)ie  of  the  author's  series  of  im- 
plantations, and  to  his  mind  is  as  con- 
chisive  eviflence  of  the  value  of  the 
work  as  a  single  case  possibly  eould  be. 
It  is  especially"  weighty  evidence  when 
considered  in  connection  with  the  ap- 
jjarent  results  of  our  other  implantation 
work. 

A  man.  a.yed  29.  sustained  an  injury 
td  his  testes  while  ])layini;-  football, 
twelve  years  before  he  consulted  the 
author,  in  July.  1915.  His  ri.yht  testicle 
was  enormously  swollen  ( projjahly  he- 
matocele) an.d  very  painful.  When  the 
swelling  subsided,  the  gland  had  en- 
tirely disa])])eared.  The  remaining 
testicle  atrophied  to  a  model  ate  de- 
gree. \'irility  was  unimpaired,  and  the 
liatient   married   three   year-    later.      <  )iie 


Kiii-.    1. 


I)i.ul,l(.    iiiiiilaiitati'Mn    of    ti'-tcs    from 
.1    lio.lv    ill    a    <::>-(•   of    .loiil>lc   oiiiiii.leto 


.nn.,,li 


eliild   was   horr.  of  the  union. 


]  A 1 POTENXE    AND    STJ'.R 1 1  <1T Y 

About  two  months  prior  to  our  examination  the  patient,  without  pre- 
cc<ling  trauma  or  known  infection,  suddenh'  developed  pain  in  the  left 
iliolnmhar  reginn.  left  spermatic  cord,  and  the  remaining  testicle.  The 
testicle  did  not  swell,  but,  the  patient  stated,  the  veins  above  it  were  swollen, 
The  temperature  record  was  not  available.  There  were  no  urinary  symptoms. 
At  the  end  of  three  weeks  the  testicle  had  coiu])letely  atrophied,  and  some 
weeks  later  the  case  was  referred  to  me. 

On  examination,  we  found  a  healthy-looking  subject,  over-fat,  with 
moderately  feminine  secondary  sex  characteristics.  The  beard  was  almost 
negligible:  the  mammae  moderately  large,  and  the  pelvis  distinctly  broader 
than  the  normal  luasculine  type.  The  patient  stated  that  his  physique  had 
shown  these  peculiarities  increasingly  since  his  injury,  twelve  years  before, 
but  that  bis  sexual  power  had  been  "satisfactory"  until  after  the  loss  of  the 
second  testicle.  During  all  these  \'ears  he  had  not  been  i)hysically  as  fit  as 
before,  and  I'or  about  a  year  be  had  with  ditbcully  met  the  physical  and 
mental  exigencies  ot'  bis  business,  this  lack  of  elliciency  having  rapidlj- 
incre.'i'-ed  since  the  hiss  ol"  the  remaining  testicle.  v^ince  tb.e  lo-s  of  the 
second   testicle   there  bad   been   com])lete   im])()teiice. 

I'alpation  showed  scarcely  a  \estige  (if  tissue  at  the  end  of  the  spermatic 
cords — nothing,  indeed,  that  could  be  accepted  as  even  a  remnant  of  gland 
tissue.  Th(.'  |)enis  was  of  only  moderate  de\'elopment,  with  a  long  prepuce, 
but    otherwise    normal. 

.August  1.  1*>15.  the  author  iiuplanted  on  this  ])atient  both  testes  taken 
from  a  boy  of  14,  dead  of  a  crushing  injury.  The  subject  was  just  approach- 
nig  puberty,  and  not  well  developed.  The  testes  were  removed  si.x  hours 
after  death,  and  kei)t  on  ice  in  sterile  salt  solution  until  the  operation, 
thirty-nine  liours  after  the  death  of  the  donor.  The  implantation  was  made 
in  the  scrotal  sac  on  each  side,  at  the  normal  site  of  the  testes.  The  glands 
were  im])laiUed  eiUire.  the  epididymes  not  being  removed.  Healing  was 
])rompt ;  there  was  only  1  degree  of  transient  febrile  reaction,  and  very 
slight  inflanuuatory  swelling  about  the  im])lanted  glands,  h'ive  days  after 
the  imi)lantation  circumcision  was  ]ierformed.  The  i)atient  returned  home 
in  two  weeks.  X'igorous  and  painful  erections  occurred  after  the  eighth  day. 
and  recpiired  an  ice  l)ag.  Successful  coitus  was  ])racticed  three  weeks  after 
dismissal  froiu  the  hospital.  Seven  months  after  o])eration,  the  patient 
reijorted  that  he  was  i)erfectly  normal,  was  taking  active  gymnastic  exercise, 
and  bad  lost  nearly  20  ixiunds  of  his  tlabby  fat.  l'',rections  vigorous  and 
more  fre(|uent  than  in  the  average  normal  subject  of  similar  age.  The 
p;itii'nl  laid  t'special  stress  on  his  mental  ;uid  physical  fitness  for  business, 
'idle  imiilanted  testes  had  atrophied  only  moderatel.w  and  were  of  relatively 
fair  size  and  fairly  normal  consistency.  The  epididymes  were  i)lainly  dis- 
tinguishable. .As  Dr.  William  T.  lU'lfield,  who  courteousl\'  exaiuined  the 
case  and  (pu'>tioned  the  patient,  remarked.  "The  testes,  while  small,  are  as 
well  (lcvc1o|)ed  and  ai)i)arently  as  normal  as  in  many  iierfectly  virile  men 
who  come  nndci'  our   obser\ation." 

-^  -  312     - 


S1-:X    r.I.AXI)    IMIT.AXTATIOX 

III  i)assint;  I  \vi>h  t"  state  tint,  fur  a  while  after  the  ini]>lantatii)n.  the 
liatieiit  experienced  iKirmal  oruasni  witliDttt  eniissidii.  He  stated  t<i  Dr. 
r.elt'ield  and  myself  that  after  a  few  weeks  he  he.yan  ti)  ha\'e  emissions  of  a 
I'onsidjrahle  anioinU  of  fluid,  and  that  these  enii^sicuis  were  almost  constant. 
The  emitted  lliiid.  while  it  has  iicit  heen  e\;iinined.  of  course  is  not  testicular 
accretion  — no  anastomosis  ha\'in,L;  heen  clone — Imt  come^  from  the  urethra. 
C'owper's  .lilands.  tlu'  i>rostate.  and  the  seminal  vesicles.  In  hrief.  it  prohal)ly 
is  Composed  of  all  the  n-nal  normal  elements  of  the  normal  semen,  save 
the  H'-ticular  secretion,  of  wliit'h  tlie  spermatozoa  are  the  important  element. 
I-'or  some  \\eel<<  after  tlie  implantation  the  jiatient  complained  of 
"fritihtfid  nervoii>nes>."  .\s  h?  descrihed.  them,  his  s_\'m]>toms  were  not 
unlike  tlm-e  iimduced  1)_\-  sirychnine  and  similar  spinal  excitants.  'Idie 
"nerv(jus"  symptom^  I'mally  disappeared..  'Idie  author  attrihuted  them  to  the 
unwdnted  do-e  of  hormone  <u;iplied  hy  the  iiiiplanted  testes,  to  which  the 
ner\ous    system    .uraduall}'   liecame   accustomed. 

.\u.i.;"usi  1.^.  ]')Ui,  iust  one  year  and  two  weeks  after  the  implantation, 
the  patient  reported  as  "tit  as  a  fiddlj."  Ide  stated  that  he  sustained  inter- 
course often  as  freipiently  as  thrice  weeklw  and  tliat  his  licalth  was  perfect. 
The  testes  still  were  in  exidence  and.  althou.uh  smaller  than  when  last 
examined,   were  well   detlned  and  of   hrm   consistency'. 

77//.S-  case  uist  reported  to  the  author  J itlx  Joth.  njiy.  Prs.  //'.  7\ 
HeU'iehl  and  J.  J .  Moiiahaii  e.vaniiiied  tJie  patient.  The  implanted 
testes  :eere  found  not  to  ha:e  atrophied  appreeiiihly  sinee  the  last 
e.vaininatioji  a  yeiir  lu-jore.  '/'he  henefieial  el'/'eets  of  the  implantation 
still  endured,  ft  :eonld  appear  that  this  ease  prohahly  proz'es  that 
pennaneney  of  result  is  possible,  not  oid\  as  to  phxsiidoyie  results, 
hnt  iilso  as  to  the  endnni/u'e  of  the  eiiiplanted  (/lands. 

.\  featiu'e  of  the  foreuoin.L;  ca-e  that  is  worthy  of  especial  comment  is 
the  preser\ation  of  virilit_\' — until  tlie  loss  ,,i  the  remainin,!.i"  gland — after 
the  accident  <>i  uKjre  than  twehe  \ears  a,L;<).  despite  the  suhsequcnt  im])air- 
ment  of  develo])ment  of  masculine  secondary  characteristics.  It  would 
seem  that:  1.  A  relati\ely  lar.ye  dose  of  hormone  is  necessar_\-  to  perfect 
de\'elopment  of  secondary  sex  characteristics.  2.  A  \ery  small  dosaiic  is 
.suflicicnt  to  preser\e  \irility.  ,i.  Onct.'  \-irilit\'  is  estahlished.  an  extremeK" 
small  dosa.ye.  of  sex  hormone  will  i)reser\e  the  psycho-sexual  and  ])h_\"sio- 
sextial  sex  characteristics  that  are  so  essential  to  potency.  it  has  heen 
ohstT\ed  that  indi\iduals  possessed  of  exceedin.ylx'  rudimentar\-  testes  often 
are  \irile.  Ind.-ed.  it  has  heen  oiu"  ex])erience  that  such  ])ersons  sometimes 
are  jjuvscssed  of  more  than  the  avera.ye  de.L;ree  of  virility.  We  recall  several 
cases  oi  cr_\|>tochidism  comiiiL;  under  our  ohser\ation  in  which  there  was  a 
normal    de.uree    of    virility    with    complete    sterility. 

It  will  he  interesiin.Li-  to  note  the  further  pro.^ress  of  the  case  relative 
t"  alriipjiy  of  the  imjilanted  .ulands. 


--  3)3 


I.MPOTKNCE   AND    STERILITY 

As  already  noted,  the  glands  after  two  years  still  are  in  fair 
eondition  and  hai'e  not  appreeiahl\  atrophied  during  the  past  year. 

Possil)ly  the  preserx  ation  of  the  epididymis  lias  something  lo  do  with 
this.  As  to  how  h)ng  the  therapeutic  results  will  endure,  one  cannot  predict. 
Prohahly  permanently,  or  at  least  long  after  the  last  vestige  of  implanted 
gland  tissue  has  disappeared.  The  author  is  confident  that,  as  long  as  even  a 
small  portion  of  the  implanted  tissue  remains,  its  favorahle  effects  will  endure. 
I^ven  though  an  occasional  repetition  of  the  implantation  should  prove  neces- 
sary to  maintain  the  ])atient's  normal  sex  standard,  the  result  still  would  he 
remarkable  and  the  scientific  status  of  the  method  sustained. 


Case  2, — This  case  was  purely  ex- 
perimental, and  no  exhaustive  report 
will  be  made  at  this  time.  The  subject 
was  a  healthy  professional  man,  aged 
58,  who  submitted  himself  to  the  ex- 
periment from  purely  scientific  motives. 
The  companion  testis  of  that  used  in 
Case  ,3  was  employed.  The  implanta- 
tion was  made  in  the  left  scrotal  sac. 
The  local  result  of  the  implantation 
was  what  we  now  feel  justified  in  call- 
ing "typic,"  save  that  the  subject  got 
about  on  his  feet  after  twenty-fotir- 
hotu's,  which  resulted  in  considerable 
swelling  and  tenderness  of  the  oper- 
ated region.  Wdien  the  patient  keeps 
to  liis  l)ed,  the  reaction  is  very  slight, 
compared  to  the  tissue  "insult." 


2. — K.\])cvinic'iit;il      iniplantation      of      a 
•single   testis   from   a   dead   body. 


In  this  case  there  was  a  rise  of  temperature  of  1  degree,  which  subsided 
in  twenty- four  hours.  Seven  months  after  the  implantation  a  nodule  about 
the  size  of  a  good-sized  grape  was  still  perceptible.  Fourteen  months  later, 
the   nodule   was   the   size  of    a   large   pea. 

Certain  oddities  of  apparent  physiologic  effects  were  noted  in  this  case, 
which,  if  sustained  by  future  observation,  will  be  reported. 


Ca.sh  3. — A  man,  aged  sixty,  ai)parently  normal  in  every  respect,  sub- 
mitted to  imi)lantation,  with  a  view  of  increasing  ])hysical  vigor  and  endurance 
in  general,  and  sexual  vigor  in  particular.  The  necessary  material  was  secured 
from  an  apparently  healthy  lad  of  seventeen  years  of  age,  dead  twelve  hours 
of  crushing  injury  to  the  head.  Death  had  occurred  about  four  hours  after 
the  injm-y.     The  operation  was  performed  shortly  after  that  in  Case  2. 

—  314  — 


Si:\    C.I.WI)    IMI'I.AXTATIOX 


The  lc>R->  were  icirii^cratcd  tor 
about  forty-cis^ht  iiours.  A  single  gland.  ! 
the  right,  was  eniplovL-d.  The  epididymis 
was  reniuved,  and  numerous  areas  of 
the  Cortex  denuded.  The  implantation 
was  made  in  the  right  scrotal  sac.  The 
implantation  was  perfectly-  successful. 
Tliere  was  practically  no  febrile  reaction, 
and  very  little  swelling  at  the  site  of 
th.e  imi)lantation.  Xo  opportunity  has 
])resented  itself  for  a  review  of  this 
case,  but  a  little  over  seven  months  after 
the  implantation  the  patient  wrote  that 
lij  was  satisfied  with  results,  and  that 
there  still  was  "([uite  a  lump"  at  the  site 
of  the  im])lantation.  Twenty-two  months 
after  the  implantation,  the  patient  wrote 
that  his  "physical,  sexual  and  mental 
vigor"  still   were  greatly  improved,  and 


1  i 

K     m           *  'dm.         M 

f 

I     SI,   II 


i|,I:int;lt 
.lia.l    1. 


1 t    a 

mIv. 


that  his  blood  pressure — which  was 


1.^0  at  the  time  of  the  implantatioii — was   Li5. 

Cask  4.  Double  testicular  implantation.  Subject  aged  sixty-nine.  Xo 
organic  disease.  Complained  of  shortness  of  breath  on  comi)arativcl\'  slight 
exertion  and  of  "im-teadiness"  of  lower  limbs.  Sexual  power  still  fair,  but 
"failing"  as  usually  might  be  expected  in  a  man  of  his  age.  lirielly.  as  the 
patient  and  his  friends  expressed  it.  he  had  begun  to  show  his  age.  His 
n,irmall\-  ruddy  complexion  had  ])aled  considerably,  lilood  pressure.  K"^0 — 
-ystolic.  I)ige-li\e  function  normal,  despite  a  ten;lency  to  o\er-cating. 
W'islies  to  submit  to  implantation  for  its  prolsable  effect  of  increased  elticiency 
juid  ini]>ro\  cment  of  -exual  jiower.  Double  :~crotal  implantation  ( )ctober  27. 
1''16.  Alaterial  taken  from  healthy  lad.  fourteen  years  of  age.  dead  about 
ten  hours  from  crushing  injury  of  the  head.  Material  refrigerated  twelve 
hours,  l-.pididymes  not  remo\'ed  and  testes  im])Ianted  intact  without  decorti- 
cation. \'erv  slight  local  reaction  and  no  temperature.  Patient  up  and  about 
on  the  eighth  day.  Improvement  in  color  was  noticeable  on  the  third  day. 
and  \\as  connnented  on  by  the  author's  assistants  and  the  i)atient's  friends. 
Six  months  after  the  implantation,  well  detfned  nodules,  insensitive  and 
ireely  movable,  marked  the  sites  of  implantation.  Atrophy  had  been  rather 
more  rapid  than  in  the  average  case.  Init  both  the  epididymes  and  the  bodies 
of  the  testes  were  plainly  to  be  felt,  the  entire  mass  on  each  side  being  about 
the  size  of  a  small  almond.  The  patient's  appearance  was  that  of  a  man  ten 
year-  younger  than  his  ,-ige.  his  face  -liowing  .a  healthfid  rucMiness.  b'.fticiency 
had  markedly  increased,  and  the  "insecurity"  of  the  lower  liml)s  had  entire!) 
disaijpearefl.  The  su])erticial  \eins  of  the  lower  extremities,  which  were 
Considerably  enlarged  and  varico-e.  had  improved  to  ;i  marked  degree.  The 
sexual    pcjwer    had    markedly    increased.      The    patient    expressed    himself    as 


315 


lAipoTi^xci-:  AND  sti<:rii<ity 

hciiiK  so  well  satisfied  with  results  that  he  had  resolved  to  have  the  implanta- 
tion repeated,  after  a  time,  if  neeessar^'  to  sustain  the  admirable  results. 

Cask  5.  Double  testieular  implantation.  This  ease  was  purely  experi- 
mental. vSubject  sixty  years  of  a^e.  Until  an  attaek  of  grippe  a  few  weeks 
before,  was  as  healthy  as  the  average  man  of  his  years.  Material  obtained 
from  a  ])owerful,  athletic  young  man,  twenly  jcars  of  age,  dead  about  three 
or  four  hours  from  contact  with  a  live  wire.  Double  scrotal  implantation. 
Epididymes  left  intact,  but  almost  the  entire  bodies  of  the  testes  decorticated. 
Considerable  local  reaction  with  marked  edema.  ISecanse  of  faulty  technique, 
ihe  implantation  on  the  right  side  was  a  failure,  the  disintegrated  gland 
being   removed   at   the   end   of   a   week,   the    wound   healing   promptly.      The 


Kit;-.    I.    -ni.!iljlc   Ini|.l:int;itinii   of  testes  tnUeii   froii 
a    (lead   ImmIv.    .^ix    weeks   after    operation. 


implantation  on  the  left  side  was  snccessfid,  l)nt  slight  infection  of  the  upper 
angle  of  the  wound  occurred:  thf  fa-cial  purseslring  ga\  e  way  a  few  days 
later  and  seminal  tubuli  api)eare(l  at  the  aperture.  Subse(iuently,  a  distinct 
mass  of  testicular  tissue  the  size  of  a  small  ])ea  protruded  from  the  wound. 
This  became  vascularized  and  for  ])ur])oses  of  study  was  removed,  showing 
the  characteristic  cut  smM'ace  of  living  testicle  substance.  Several  weeks 
later,  tlie  surfaci'  again  became  \ascnlarized,  api)earing  like  a  small  segment 
i)f  cherry.  Two  months  later,  the  implanted  testicle  was  firm  and  hard  and 
tile  size  of  an  luiglish  walnut;  the  small  mass  of  li\ing  testicular  tissue 
still  was  in  evidence.  .V  small  amount  of  iJiu'idoid  st'cretion  issued  from 
the  small  -iirface  of  exjiosed  testis  and  the  ti-^snes  of  the  wound.  This 
showed  an  abundance  of  leucocytes  but  no  organisms  were  found.  The 
])atient  show  I'll  increase  in  inentil  and  |)hysical  eflicienc^-  and  his  \  igor 
grt-at1.\-  iinpi"o\ed.  There  was  a  distinct  improvement  in  vascular  tone  and 
in    the    heart's    action.      lUood    pressure    had    been    ct)nsiderabl\-   lowered    and 

—  316    - 


SEX    GLAND  IMPLANTATION 

the  heart's  action  became  weak  following  the  grippe  toxemia,  being  only  about 
115  (systolic)  at  the  time  of  the  implantation.  Two  months  later  the  blood 
pressure  was  130.  The  patient's  color  markedly  improved,  the  improvement 
being  noticeable   within   ten   days   after   the    implantation. 

Case  6.  Double  testicular  implantation.  Subject,  a  boj'  nineteen  years 
of  age,  with  the  following  history:  At  the  age  of  thirteen  he  suffered 
severely  from  a  vaccination,  probably  with  a  mixed  infection.  Shortly  after 
the  vaccination,  which,  he  stated,  made  him  very  ill,  he  developed  orchitis 
in  one  testicle,  probably  from  an  infected  embolus.  Following  the  orchitis 
the  testicle  atrophied.  Several  weeks  later  the  opposite  testicle  became 
similarly  involved  and  speedily  atrophied.  Coincidentally  the  penis  became 
distinctly  smaller.  Some  months  later  the  case  was  examined  by  several 
surgeons  who  diagnosed  retained  testis  on  the  left  side  and  suggested  opera- 
tion. The  case  subsequently  was  referred  to  the  author.  Patient  now  was 
seventeen  years  of  age.  Examination  showed  a  tall,  healthy  looking  subject 
with  distinct  feminine  secondary  sex  characteristics.  Pelvis,  mons  veneris 
and  mammary  glands  suggestive  of  a  female  just  entering  upon  puberty. 
No  beard  was  in  evidence  and  the  complexion  was  distinctly  of  the  "milk 
and  blood"  feminine  type.  There  was  a  bare  suggestion  of  hair  upon  the 
pubis.  The  left  testicle  was  represented  b}'  a  small,  hardly  perceptible  nodule 
about  as  large  as  a  small  pea  just  below  the  external  inguinal  ring.  The 
right  testis  was  soft  and  about  the  size  and  shape  of  a  small  lima  bean.  The 
penis  was- no  longer  than  that  of  a  well  developed  child  of  five  or  six  years  of 
age.  The  voice  was  that  of  the  usual  boy  of  seventeen.  Psychically,  the  boy 
fortunately  was  a  normal,  manly  fellow,  although  there  were  no  signs  of 
virility. 

After  some  six  months'  treatment  with  faradism  with  some  slight 
improvement,  the  author  suggested  an  implantation.  Other  advice  was 
sought  and  several  surgeons — one  supposedly  an  authority — suggested  opera- 
tion for  retained  testis,  despite  the  feminine  sex  characteristics  and  local 
conditions  which  plainly  showed  the  absurdity  of  such  an  operation.  The 
case  passed  from  under  observation  and  did  not  return  to  the  author  until 
two  years  later,  when  he  found  that  an  operation  had  been  performed  on  the 
left  side,  with  the  inevitable  result  that  the  remnant  of  testicle  on  that  side 
had  completely  disappeared. 

At  the  second  examination  the  condition  in  general  was  the  same  as 
it  was  two  years  before,  save  that  the  secondary  feminine  sex  characteristics 
were  more  pronounced.  There  still  had  been  no  manifestations  of  virility. 
The  pelvis  was  distinctly  feminine  and  the  mons  veneris  covered  with  a  well 
pronounced  cushion  of  fat  and  sparsely  supplied  with  hair,  the  arrangement 
of  which  was  distinctly  that  of  a  young  girl  approaching  pubert3^  The 
beard  still  was  lacking.  Implantation  of  testes  again  was  suggested  and 
consented  to. 

Operation  performed  October  27,  1916.  Material  used  was  taken  from 
a  healthy  boy  fifteen  years  of  age,  dead  twenty-four  hours  of  carbon  mon- 
oxide   poisoning.      Glands     refrigerated    32    hours.       Scrotal     implantation. 

—  317  — 


IMPOTENCE   AND   STERILITY 

Epididymes  were  not  removed  and  testes  were  not  decorticated.  There  was 
very  little  reaction  and  practically  no  temperature  following  the  operation, 
but  the  patient  was  kept  in  bed  for  ten  days. 

Six  months  after  the  implantation,  the  implanted  testes  still  are  well 
defined,  the  right  gland  being  much  larger  than  the  left  and  as  large  as  that 
of  the  average  lad  of  twelve.  The  consistency  of  both  glands  is  softer  and 
more  nearly  approximates  the  normal  than  have  any  others  thus  far  implanted. 
The  patient  has  gained  weight  and  strength  and  is  virile,  as  demonstrated  by 
moderately  frequent  erections  and  the  fact  that  he  has  cohabited  thrice  in  suc- 
cession on  four  occasions,  with  orgasm,  but  no  emission.  Penile  develop- 
men  has  greatly  increased  and  the  pubic  and  scrotal  hair  also  has  increased 
and  assumed  a  more  masculine  type.  The  lines  of  the  patient's  body  have 
changed  appreciably  and  become  more  masculine  in  conformation,  the  cushion 
of  fat  upon  the  moiis  veneris  especially,  being  reduced  in  size.  The  patient's 
own  atrophied  right  testicle  has  increased  in  size  and  firmness  and  the 
epididymis — which  could  not  be  discerned  at  the  time  of  the  implantation — 
now  can  be  plainly  outlined.  The  voice  is  distinctly  more  masculine ;  the 
beard  is  heavier  and  a  growth  of  hair  has  appeared  on  the  forearms. 

The  foregoing  case  alone  appears  to  the  author  as  conclusive  a  proof  as 
could  be  desired  of  the  remarkable  effects  of  sex  gland  implantation. 

The  author  had  the  honor  of  exhibiting  this  case  to  a  number 
of  the  members  of  the  American  Urological  Association  during  the 
recent  Chicago  meeting.* 

At  present  writing  the  author  not  only  feels  that  his  heretofore 
published  impressions  of  the  value  of  the  sex  gland  implantation — 
notably  in  the  matter  of  increasing  physical  efficiency,  and  especially 
physio-sexual  efficiency — have  been  confirmed  by  further  experience, 
but  also  is  convinced  that,  when  technic  and  material  are  right  and 
the  recipient  properly  selected,  continuity  of  hormone  production  by 
the  implanted  gland  for  at  least  a  prolonged  period  is  certain.  That 
permanently  beneficial  physiologic  and  therapeutic  results  are  equally 
certain  seems  probable.  Thus  far  we  have  observed  no  case  in  which 
the  implanted  tissue  had  completely  disappeared,  or  even  practically 
so,  prior  to  from  twelve  to  eighteen  months.  In  brief,  the  author 
is  convinced  that  his  method  of  sex  gland  implantation  long  since 
has  been  taken  from  the  purely  experimental  field  and  that  it  now 
stands  on  firm  ground  as  a  valuable  therapeutic  resoinxe. 

The  endeavor  has  been  made  fairly  to  present  the  work  of 
others  whose  labors  have  touched,   even  remotely,  upon  the  field 


*  While  this  work  was  soin^?  through  the  press  the  author  performed  four 
ndditional  (beins  two  double)  implantations.  These  were  perfectly  successful. 
but   it    is   too   eai-ly   to   arri\e   at   definite   conclusions   as   to   therapeutic   results. 

—  318  — 


SEX    GLAXD   niPLAXTATIOX 

covered  by  the  author's  researches,  hence  it  may  not  be  deemed 
improj)er  to  call  attention  to  the  main  features  of  originality  in  the 
imj)lantation  work  herein  presented,  viz. : 

1 — The  first  implantation  of  an  entire  human  testis  for  thera- 
])eutic  or  ex])erimental  purposes. 

2 — The  first  successfid  implantation  of  human  sex  glands — 
ovary  or  testis — taken  from  the  dead  body. 

.3 — The  first  study  of  the  general  physiologic  effects  of  the  hor- 
mone from  implanted  testes  and  ovaries. 

-1 — The  first  demonstration  of  microscopic  sections  from  im- 
planted human  or  lower  animal  testes  proving  their  survival. 

5 — The  first  demonstration  of  the  acquirement  of  new  circula- 
tion by  implanted  sex  glands — either  human  or  lower  animal. 

6 — The  first  cross  implantation  of  human  sex  glands. 

7 — The  first  experimental  implantation  of  sex  glands  in  de- 
mentia prsecox,  senility,  and  feniinism  due  to  aberrations  of  testicu- 
lar structure  and  function. 

8 — The  first  studies  of  the  eft'ects  of  sex  gland  im})lantation 
upon  senility,  the  skin,  blood  vessels,  blood  and  nervous  system. 

9 — Formulation  of  a  practical  technique  for  sex  gland  im- 
plantation. 

10 — I'robable  refutation  of  the  belief  that  glands  from  alien 
sources  cannot  survive — at  least  for  a  considerable  period — after 
implantation. 

11 — Possible  —  or  even  probable  —  permanency  of  duration  of 
glands  from  alien  sources  in  some  cases. 

COXCLUSIOXS. 

1.  At  least  temporarily,  possibly  permanently- — and  indubitably 
therajieutically — successful  total  or  partial  implantation  of  human 
sex  glands  in  both  male  and  female  is  practicable. 

2.  Glands  taken  from  the  living  subject  are  most  desirable, 
though  rarely  obtainable.  They  are.  however,  not  more  viable  than 
those  taken  from  somatically  dead  subjects.  The  closer  the  blood 
relationship  of  donor  and  recipient  the  better,  but  such  relationship 
is  not  necessary  for  purely  therapeutic  purposes. 

—  319  — 


IMPOTENCE  AND   STERILITY 

3.  Judging-  by  his  own  early  autoexperiment  and  heteroexperi- 
ments,  and  with  due  respect  to  Carrel's  observations,  the  author  at 
first  concluded  that,  while  glands  frozen  before  decomposition  may 
be  available,  they  should,  if  possible,  be  used  without  freezing  and 
very  promptly  after  removal  from  the  body,  to  obtain  a  fair  average 
of  successes.  He  now  believes  that  nothing  is  lost  by  ordinary 
refrigeration  for  twenty-four  to  forty-eight  hours.  Glands  taken 
from  the  healthy  dead  body  at  any  time  prior  to  the  beginning  of 
decomposition  are  of  therapeutic  value  equal  to  that  of  those  taken 
in  vivo.  Portions  of  glands  are  to  a  certain  degree  therapeutically 
serviceable,  according  to  conditions  and  dose. 

4.  While  in  certain  cases  we  might  be  warranted  in  incurring 
some  risk,  the  subject  from  which  the  glands  are  taken  should  be 
selected  with  extreme  care. 

5.  The  ovary  and  the  testis  probably  are  alike  in  their  suscepti- 
bility to  implantation,  both  from  the  living  to  the  living  and  from 
the  dead  to  the  living.  If  any  difference  exists,  it  possibly  is  in 
favor  of  the  ovary.  In  human  beings,  the  gland  of  one  sex  is  trans- 
plantable upon  the  other,  and  it  is  possible  that  the  hormone  of  the 
one  is  useful  to  the  other.  The  author's  experiments  apparently 
show  that  the  tissues  of  the  female  are  quite  as  hospitable  to  the 
implanted  male  sex  glands  as  are  the  tissues  of  the  male.  New 
l)lood  vessels  are  formed  as  early  as  the  eighth  day. 

6.  The  benefits  of  implantation  probably  accrue  irrespective 
of  the  site  of  the  implantation,  but  the  vicinity  of  the  peritoneum 
(extra  abdominal)  in  the  female,  and  of  the  tunica  vaginalis  in  the 
male,  are  the  sites  of  selection. 

7.  The  internal  sex  gland  secretion  is  stimulant,  nutrient, 
tonic,  and  reconstructive,  and  should  increase  resistance  to  disease. 
Certain  chronic  infections,  notably  tuberculosis,  serious  anemia, 
neurasthenia,  and  conditions  of  profound  debility  should  be  benefited 
by  implantation.  In  brief,  any  chronic  disease  in  which  improve- 
ment of  nutrition  is  a  desideratum  should  be  benefited  by  sex  gland 
implantation.  Blood  regeneration — notably  increase  in  hemoglobin 
— is  here  a  powerful  factor. 

8.  The  development  of  senility  apparently  can  be  retarded  to 
a  greater  or  less  degree,  and  longevity  possibly  increased  by  internal 
sex  secretion  derived  from  implantation.     The  climacteric  probably 

—  320  — 


SEX    GLAND   IMPLANTATION 

can  be  postponed  by  it,  or  the  disagreeable  features  of  the  chmac- 
teric  reheved. 

9.  Used  at  a  very  early  period  in  the  disease,  internal  sex 
secretion  theoretically  should  be  the  logical  remedy  for  dementia 
precox  and  allied  conditions. 

10.  The  internal  sex  gland  secretion  via  implantation,  has  a 
very  useful  field  in  the  treatment  of  impotence  in  the  male. 

11.  Implantation,  with  or  without  anastomosis  in  the  male, 
possibly  may  have  a  certain  range  of  usefulness  in  sterility  in  both 
sexes. 

12.  Defective  and  aberrant  psychical  or  physical  sex  develop- 
ment and  differentiation — inversions  and  perversions — are  definite 
indications  for  sex  gland  implantation.  Certain  cases  of  cryptor- 
chidism and  imperfect  testicular  development,  or  atrophy  from 
disease,  are  an  especially  promising  field  for  it. 

13.  Intractable  neurasthenia  probably  is  relievable  by  it  in  a 
large  proportion  of  cases. 

14.  Chronic  diseases  of  the  skin  due  to,  or  modified  by  nutri- 
tional disturbances — notably  certain  types  of  chronic  eczema,  psor- 
iasis, and  ichthyosis — in  a  certain  proportion  of  cases  apparently 
are  likely  to  be  benefited,  and  possibly  cured  by  sex  gland  im- 
plantation. 

15.  That  arteriosclerosis  will  in  its  early  stages  be  benefited 
by  sex  gland  implantation  is  probable.  Inferentially,  if  taken  early, 
senile  dementia  possibly  may  show  beneficial  results.  It  has  a 
positive  action  in  restoring  blood  pressure  equilibrium  and  improving 
cardiac  tone  and  efficiency. 

16.  All  conditions  incidental  to  sex  gland  mutilations  in  either 
sex  afiFord  a  positive  indication  for  sex  gland  implantation,  the 
])robability  of  benefit  being  inversely  as  the  length  of  time  that  has 
elapsed  since  the  mutilation,  and  dependent  on  the  age  at  which  it 
occurred. 

17.  Such  diseases  as  chronic  nephritis  and  diabetes  would  seem 
to  be  indications  for  implantation. 

18.  What  is  true  of  sex  gland  implantations  in  a  general  way, 
probably  applies  to  implantation  of  other  organs  taken  from  dead 
human  bodies  in  various  diseases. 

—  321  — 


IMPOTENCE   AND    STERILITY 

19.  The  most  important  point  of  all  is  that,  in  properly  selected 
cases,  successful  implantation  ought  inevitably  to  increase  physio- 
logic efficiency,  with  all  the  benefits  accruing  therefrom.  With 
increased  physiologic  efficiency  come  individual  and  social  efficiency. 

20.  Opportunities  should  be  sought  in  the  human  subject  for 
histologic  study  of  implanted  glands  at  varying  periods  after  im- 
plantation, to  determine  in  what  degree  both  generative  and  internal 
secretion  gland  tissues  endure. 

21.  Every  efifort  should  be  made  to  so  amend  our  laws  that 
viable  tissues  of  all  kinds,  notably  internal  secretory  glands,  shall 
become  available  to  science.  To  this  end  the  public  especially  should 
be  made  to  understand  that  the  sacrifice  of  a  portion  of  thyroid  or 
of  a  single  ovary  or  testis  by  a  living  subject  is  not  disastrous.  The 
author  believes  that  there  are  times  when  tissues  obtained  by  such 
a  sacrifice  will  restore  reason,  perhaps  even  life.  Legislation  and  pub- 
lic sentiment  should  favor  scientific  research.  Between  the  antivivi- 
sectionists,  on  the  one  hand,  and  popular  reverence  for  the  dead 
human  body,  on  the  other,  we  are  in  sore  straits.  Why  should  there 
be  a  waste  of  material  which,  if  properly  used,  possibly  might  add 
so  much  to  the  health,  happiness,  efficiency,  and  even  to  the  longevity 
of  the  human  race?  Let  us  strive  for  the  conservation  of  biologic 
energy. 

As  matters  now  stand,  only  persons  in  affluent  circumstances, 
and  very  few  even  of  these,  and  a  limited  nimiber  of  the  poor  in 
our  institutions  can  avail  themselves  of  sex  gland  or  other  organ 
implantations.* 


*  Those  interested  in  tlie  dates  of  publication  of  the  author's  various 
papers  on  sex  gland  implantation  are  referred  to  the  Bulletin  of  The  Chi- 
cago Medical  Society  for  March  7,  1914,  and  the  N.  Y.  Medical  Journal  for 
March  21,  April  4,  July  11,  October  17,  24,  31,  and  November  7,  1914.  In  the 
latter  number  of  the  Journal  will  be  found  a  fairly  complete  bibliography. 

The  author  desires  to  express  liis  thanks  to  Dr.  C.  E.  M.  Fisher,  Dr. 
Thomas  L.  Dagg,  Mi.ss  Agnes  Howard,  and  Dr.  Mabel  M.  Mathies  for  their 
intelligent  co-operation  in  preparing  his  microscopic  sections,  and  Mr.  F.  T. 
Harmon  for  his  splendid  worlc  in  reproducing  them  by  photomicrography. 
Magnifications  from  40  to  GO  T\^inkle  40  m.m.  objective  with  No.  4  or  No.  6 
eye  piece.  From  60  to  90  Winkle  25  m.m.  objective  with  No.  4  or  No.  6  eye 
piece.  32.5  to  400  Zeiss  8  m.m.  with  No.  6  eye  piece.  Drawings  by  Dr.  Zan 
O.  Klopper. 


—  322  — 


INDEX 


Abderhalden  test,   in   dementia  pnecox       252 
Aberrant  differentiation  of  sex       7 
— ■  classification   of       12 

—  etiology  of       14-16 

—  relation  of,  to  impotencj'-  and  sterility       16 

—  treatment  of,  by  sex  hormone       17 

Abuse  of  sexual  apparatus,  relation  of,  to  sterility       111 
Acton — 

• —  continence  in  youth       86 

— ■  definition  of  spermatorrhea       171 

—  sexual   desire   in   women       162 

—  symptoms  of   masturbation       70 

—  views  of  sexual  sensibility      69 
Acquired  sex  deformities       22 
Affinity,   relation  of,  to  sexuality       125 
Alcohol,  as  a  cause  of  impotence       137 
Amputation  of  penis  by  jealous   wife       22,  23 
Anaphrodisiacs,  use  of,  in  spermatorrhea       194 
Anastomosis  of  vasa  deferentia       94 

—  case  of,  in  gland  implantation       278 

—  technique  of      94,  95 

Animal  extracts,  use  of.  in  sexual  disturbances       196,  208 
Aphrodisiacs,   use  of,   in   spermatorrhea       194 
Asexualization       92 

—  of  the  female      96 
Aspermia — 

— ■  case  of       153,   154 

—  treatment   of       156 

Autolysis,  functional,  of  gland  tissue       230 
Auto-implantation  of  testis       225 
Azoospermia       180 

Bandler,  ovarian  extract  in  dysmenorrhea       276 
Bartholow — 
— ■  definition  of  spermatorrhea       171 

—  potassium  bromide  in  impotence       145 

—  remarks  on   pseudo-spermatorrhea       181.   184 
Bayliss  S:  Starling,   definition  of  hormone       213 
Bell,  correlation  of  internal  secretions       271 

—  2>2o  — 


I^IPOTENCE   AND   STERILITY 

Belot,  popular  presentation  of  sexual  perversion       51 
]>ernard,  glycosuria  function  of  the  liver       212 
Berthold,  transplantation  of  testes      210 
Biedl— 

—  effect  of  X-ray  on  Graafian  follicles      222 

—  formation  of  antibodies  by  hormones       214 

—  interstitial  cells  of  ovary      222 

— •  relation  of  hormone  to  secondary  sex  characters      219-220 
Blood  pressure,  effect  of  sex  gland  implantation  upon      244 
Boarding  schools,  dangers  of      51 
Bordieu,  views  of  glandular  secretion      209 
Bouin,  interstitial  cells  of  ovary      222 
Bouin  &  Ancel,  interstitial  cells  of  testicle      218 
Brown-Sequard,  self-experimentation  of      207-212 

Cantharides,  aphrodisiac  action  of      193 

Capon,   implantation  of  testis  in      280-282 

Caput  gallinaginis,  irritability  of,  in  spermatorrhea       173 

Carrel  &  Guthrie,  observations  on  transplanted  glands      247 

Cavernositis,  as  a  cause  of  impotency      136 

Celebrities,  dangerous  examples  of      28 

Cell  changes  in  implanted  testes      301 

Cevelotto,  implantation  of  testicle  tissue  in  rabbits      211 

Circulation,  effect  of  sex  gland  implantation  upon      245 

Circumcision      88 

—  as  a  remedy  for  genital  irritation      89 

—  for  nervous  diseases      89 
— •  proper  method  of      89 

Cirrhosis  of  liver,  case  of  sex  gland  implantation  in      264 
Clevenger,  sexual  perversion,  theory  of      38 
Climacteric,  in  the  male      209 
Clitoris,  hypertrophy  of       13 
Coitus — 

—  interrupted,  evils  of      84 

—  necessitj'  of,  pernicious  ideas  regarding      85 

—  proper  frequency  of      80 

—  unphysiologic   forms   of       84 
ColUculus  seminalis — 

—  cauterization  of       198 

—  relation  of,  to  impotence       145 
Compatibility  in  marriage       124 
Complementary   hormone       271 

Conception,  fear  of,  as  a  cause  of  sterility       170 
Congenital  deformities  of  urethra      19 
Connective  tissue,  protection  of  implanted  tissue  from      236 
Conservation  of  testicle  tissue      214 

—  324  — 


INDEX 

CenUinence — 

—  as  a  cause  of  impotence       118 

—  in  the  young,  beneficial  effect  of       79 

—  practibility  of      86 

Corpus  luteum,  structure  of       216 
Cross  breeding,  effect  of,  on   fertility       161 
Cross  implantation  of  sex  glands       242,  259,  278 
Cryptorchidism,   sterility  in       106 

Dallinger,  essay  on  cannibalism  in  copulation       38 
Dam  i  ana — 

—  as  an  aphrodisiac       157 

—  properties  of       192 

Deformities  of  sexual  organs,  acquired      22 

Dementia  precox,  sex  gland  implantation  in      257,  303 

Determination  of  sex       18 

Diet,  relation  of,  to  sexual  instinct      87 

Diseases  of  the  sexual  function  and  instinct      25 

—  general  considerations  of      25 
Drugs — 

—  production  of  impotency  by      137 

—  treatment  of  impotency  by      142,  143,  144 
Dubois  &  Boulet,  effect  of  prostate  extract      276 
Duration  of  procreative  power       157 
D_vsmenorrhea,  ovarian  extract  in       276 

Early  sexual  indulgence,  effects  of      29 
Electricity,  treatment  of  impotency  by      145 
Emotions,  effects  of,  on  sex  glands       130 
Emulsions  of  organs,  as  a  therapeutic  resource       197 
Environment,  relation  of,  to  sexuality      27 
Epididymis,  role  of,  in  hormone  production      295 
Epididymitis,  relation  of,  to  sterility       107 
Epididymostomy,  treatment  of  sterility  by       114 
Epididymotomy,  as  a  prophylactic  of  sterility       113 
Epileptic  attack,  resemblance  of  orgasm  to       67 
Epilepsy,  relation  of,  to  masturbation       76 
Epispadias       19 
Erection — 

—  physiology  of       97 

—  reflex  apparatus  of       98 
Erotomania      56 

Exercise,  beneficial  effects  of  on  the  sexual  system      ^ 
Exhausting  diseases,  production  of  impotence  by       121 
Exhibitionists       48 
Experimental  implantation  of  human  sex  glands       225,  277 

—  325  — 


LAIPOTENCE   AND    STERILITY 

Familiarity,  undue,  as  a  cause  of  marital  infelicity       126 
Fauser,  observations  of  dementia  prsecox       252 
Female  children,  masturbation  in       64 

—  relative  frequency  of  masturbation  in       64 
Fertilization,   process  of       159 

Flint,  vicvv-s  of  spermatorrhea       181 
Foa,  observation  on  testicle  grafts       210 
Foreign  bodies,  use  of,  by  masturbators       47 

—  case  of       48 

Formative  energy  of  spermotozoa  and  ovule       216 

Fowls,  experiments  in  implantation  of  sex  glands  in       280 

Fraenkel,  structure  of  corpus  luteum       216 

Freezing,  effect  of,  on  gland  tissue      230 

Frigidity       161 

—  relation  of,  to  sterility       162 
furor  iitcrinns       56 

Garre,  thyroid  implantation       276 

General  health,  relation  of,  to  vitality  of  spermatozoa       111 

Genital  irritation,  relation  of,  to  masturbation       62 

Genital  malformations       12 

Germinal  selection       18 

Goethe,  elective  affinities,  theory  of       129 

Gonorrhea,  relation  of,  to  sterility       107 

Guthrie,  experiments  in  ovarian  grafting      211 

GuJ^  classification  of  genital  malformations       13 

Gymnastics,  special  forms  of,  relation  of  to  masturbation       66 

Flammond — 

—  psychic  impotency,  case  of       129 

—  remarks  on  the  treatment  of  impotency       141 
Hammond   and   Sutton,  case  of    unsuccessful   testicle   implanta- 
tion     210 

Hassel.  views  of  spermatorrhea       181 
Heredity,  relation  of,  to  sexual  perversion       47 
Hermaphroditism       7 

—  case  illustrating  difficulty  of  diagnosis       10 

—  definition  of       8 

—  forms  of       13 

• —  ignorance  regarding       12 

—  occasional  difficulty  of  diagnosis       8 
Hcteroijlastic  grafting  of  testicle       308 
Hippocrates,  description  of  spermatorrhea       171 
Holmes,  observations  on  dementia  prsecox       252 
Hormone,  complementary  to  sex  gland       271 
IIorsc-l)ack  riding,   effect  of  in   spermatorrhea       175 

—  326  — 


INDEX 

Howe,  impotence  clue  to  continence,  case  of       119 
lluniicr,  relation  of  to  sexual  affinity       39 
Hypospadias       19,  21 

—  impotence,  produced  by       148 

Idleness,  relation  of,  to  sexual  vice       86 

Ignorance  of  sexual  physiology,  relation  of  to  sexuality       29 

Implantation  of  testis,  technique  of       231 

Impotence — 

—  general  considerations  of       97 

—  in  the  female       159 

—  in  the  male       115 

—  etiology  of       116 

—  symptomatic,  from   fevers       135 

—  treatment  of       138 

—  true  form,  etiology  of       133 

—  varieties  of       117 
Infertility — 

—  biochemic  explanation  of       100 

—  hormone  incompatability  in       100 
Injuries  of  the  prostatic  urethra — 

—  relation  of.  to  sterility       108 

—  relation  of.  to  impotence       108 
Insanit_v,  as  a  result  of  masturbation       IZ,  76 
Intimacies  among  children,  dangers  of       63 
Iscovesco.  lipoid  extracted  from  ovary  and  testis       276 

"Jack  the  Clipper  psychopaths       46 

Kehrer.  causes  of  childless  marriages       105 
Krafft-Ebing — 

—  remarks  on  sadism       39 

—  inverted  sexuality,  case  of,  in  the  female       43 

—  inverted  sexualitj',  case  of,  in  the  male       43 

Lallemand.  description  of  masturbators       71 

—  seminal  losses       175 

Leopold-Levi.  treatment  of  psoriasis  by  thyroid  extract       276 

Leydig,  "between  cells"  of  testicle       218 

Libidinousness.  excessive       55 

Lipoid,  extracted  from  ovary  and  testis       276 

Literature,  pernicious,  effect  of,  on  sexuality      29 

Local  results  of  sex  gland  implantation       236 

Lode,  observations  of  testicle  transplantation       211 

Loisel,  toxic  extracts  from  sex  glands       217 

—  327  — 


IMPOTENCE  AND   STERILITY 

Longevitj' — 

—  eflfect  of  sex  hormone  upon      272 

—  relation  of  sex  vigor  to      207 

Male  climacteric      209 

Marital  infelicity,  responsibility  of  husband  in       126 
Marital  relation,  mismanagement  of,  by  husband       163 
Marriage — 

—  as  a  remedy  for  masturbation      91 

—  as  a  remedy  for  sexual  disturbances       198 

Marshall  and  Hammond,  experiments  in  controlling  sex  charac- 
teristics of  sheep      219 
Masochism      48 

Massage,  prostatic,  treatment  of  impotence  by      48 
Masturbation      61 

—  among  animals      61 

—  as  a  cause  of  insanitj'      IZ 

—  ethology  of      62 

—  frequency  of      62 

—  in  3^oung  children      62 
• —  prognosis  in      90 

—  relation  of  genital  irritation  to      62 

—  results  of      71 

Material  eligible  for  sex  gland  implantation       138 
Mental  disquiet,  production  of  pseudo-impotency  by       121 
Metchnikoff 

—  experiments  with  semen      274 
Michel,  functional  autolysis      231 

AIoll,  substances  controlling  secondary  sex  characteristics      219 

Monogamy,  artificial  nature  of  man      26 

Mons  veneris,  as  a  site  for  sex  gland  implantation      234 

Moral  degeneracy,  relation  of,  to  marital  infelicity       126 

Morris,  heteroplastic  grafting  of  testicle      308 

Mutilation  of  sexual  organs      21,  22 

Miiller,  views  of  ductless  glands      209 

Necrophilism      48 
Neurasthenia,  sexual      200 

—  treatment  of,  by  sex  gland  implantation      255 
Normal  persons,  sterility  in       111 

Novelty,  relation  of,  to  sexual  desire      56 

—  relation  of  sex  hormone  to      58 
Nussbaum,  origin  of  sex  hormone       216 
Nymphomania      52,  56 

—  etiology  of      58 

—  treatment  of       59 

—  hormone  therapy  in       60 

—  328  — 


INDEX 

Nymphomaniacs,  fondness  of,  for  gynecologic  manipulations       57 

Obesity,  effect  of,  on  sexuality      221 
Olfaction,  relation  of,  to  sexual  desire      39,  137 
Orchitis,  relation  of,  to  sterility       107 
Orgasm — 

—  accidents  produced  by      68 

—  in  the  female      68 

—  resemblance  of,  to  epileptic  attack      68 
Ovarian  implantation       222 

—  case  of      249 

—  sites  for      235 

Ovarian,  irritation,  relation  of.  to  sexual  perversion       46 
Ovary — 

—  diseased,  conception  in  presence  of       165 

—  effects  of  implantation  of      222 

—  internal  secretion  of      222 

—  secretory  cells  of      222 
Ovule— 

—  vitality  of,  in  relation  to  sterility       110,  159 

—  conditions  impairing"  vitalit}'  of       161 

Paschoud,  thyroid  grafting      213 
Passion  in  women,  psychic  inhibition  of       164 
Perineal  strain,  dangers  of       67 
Peyer,  definition  of  spermatorrhea       174 
Phimosis,  as  a  factor  in  masturbation      63 
Phthisis,  relation  of,  to  masturbation       76 
Physical  training — 
— •  benefits  of,  in  sexual  disturbances      86 

—  in  spermatorrhea       172,  179 

Physiologic  effects  of  sex  gland  implantation       243 
Pilocarpin,  administration  of,  in  impotence       121,  136 
Plumage,  in   fowls,   as   a   criterion   of    secondary   sex   character- 
istics  (foot  note)       212 
Poehl,  injections  of  spermine       212 
Polygamous  nature  of  man       27 
Pornography      48 
Porte  caustiqiie       198 

—  sterility  produced  by       108 
Potency — 

—  following  castration,  explanation  of       103 

—  after  castration,  with  sterility      104 
Precocious  sexuality      23 

—  etiology  of      24 

Prenant,  structure  of  corpus  lutcuin      216 

—  329  — 


IMPOTENCE   AND    STERILITY 

Preservation  of  sex  gland  tissue  for  implantation      230 
Profession,  responsibility  of.  for  sexual  ignorance       30,  31 
Properitoneal  space,  as  a  site  for  sex  gland  implantation      234 
Prostate — 

—  hormone  of       200 

—  irritation  of,  in  relation  of,  to  libidinousness       55 
Prostatic  urethra,  applications  to,  in  spermatorrhea       196 
Prostatitis,  sexual  phenomena  in       183 
Pseudo-hermaphroditism       7,   8,    10-13,    15,   20 
Pseudo-impotence       116 

Pseudo-spermatorrhea       172,   177 
Psoriasis,  sex  gland  implantation  in,  case  of       264 
Psychic  impotency,  causes  of       127,  129,  132 
Psycho-sexual  failure  of  differentiation       14 
Psycho-therapy- — 

—  treatment  of  impotence  by       138 

—  treatment  of  spermatorrhea  by      50 

Quantity  of  sex  gland  tissue  for  implantation       237 

Racial-cross  sex  gland  implantation,  cases  of       241,  277,  278 

Ramm-White  operation      206 

Rationale  of  sex  gland  implantation       238 

Rectum,  disease  of,  as  a  cause  of  impotence       118 

Regaud  &  Policard.  secretory  cells  of  ovary      222 

Religious  psychology,  relation  of,  to  masturbation       75 

Repression  of  sexual   desire   in  women,  cause  of       122 

Resection  of  vasa  dcfcrcntia       92 

Resection  of  vena  dorsaUs  penis  in  treatment  of  impotence       149 

Reynolds,  sexual  perversion,  peculiar  case  of       47 

Ribbert,   transplantation  of  tissue       211 

Roubaud,  psychic  impotency,  typic  case  of       127 

Sadism       39 

—  cases  of      47 
Satyriasis       52 

—  associated  with  sexual  perversion,  case  of       54 

—  typic  cases  of      53 
— ■  etiology    of       53 

—  in  elderly  men       54 

Schiefferdeckcr,  physiologic  action  of  internal  secretions       214 
Secondary  sex  characteristics — 

—  substances  controlling      219 

—  preservation  of,  after  castration       219 

—  330  — 


INDEX 

Secretion — 

—  lack   of,    in    impotence       121 

—  treatment    of,    by    pilocarpin       121-144 
Semen — 

—  normal,  microscopic  appearance  of       178 

—  microscopic  appearance  of,  in  sperniuria       182 

—  perversion  of,  relation  of.  to  sterilitj-       110 
Seminal   losses       175 

—  etiology  of       176 

—  treatment  of       186 

Sensitive  sexual  organization,  relation  of,  to  impotence       122 
Sex  deformities       7-10,  12-23 
Sex,  determination  of       18,  19 
Sex  gland  implantation       205,  245 

—  cases  of      249,  250,  257,  258,  259,  264,  111,  278.  303,  311,  314, 

315,  316,  317 

—  effect  of  senile  environment  upon       269 

—  technic  of       225 
Sex  hormone— 

—  relation  of,  to  aberrant  sex  differentiation       16 

—  incompatability  of,  as  a  cause  of  sex  aberrations       17 
Sex  mutilation,  ph^-siology  of       22 

Sexual  abuse,  as  a  cause  of  sterility       111 
Sexual  desire,  repression  of       123 
Sexual  erethism       55 
Sexual  excess      78 

—  impairment  of  semen  by       '^2 

—  injury  to  sexual  function  produced  by       83 

—  local  and  general  results  of       82 

—  perversion  of  internal  secretion  by       79-83 

—  treatment  of       84 

Sexual  excitement  v.-ithout  gratification,   results   of       175 
Sexual  function  and  instinct — 

—  diseases  of      25 

—  purpose  of  25 

Sexual  irritability  in  tubercular  subjects       S3 
Sexual  neurasthenia       200 

Sexual  passion,  variation  of  intensity  of       120 
Sexual  perversion  and  inversion       31 

—  as  a  cause  of  impotence       130 

—  atavism  in       35 

—  classification  of       2)1) 

—  etiology  of       34 

—  heredit}-  in       36 

—  psycho-therapy  in       49 

—  scriptural  history  of       34 

—  331  — 


IMPOTENCE  AND   STERILITY 

Sexual  perversion  and  inversion — 

—  sterilization  for      51 

—  treatment  of      50 

—  typic  cases  of      40,  43 

Sexual  precocity,  relation  of,  to  masturbation      23 
Sexual  sensibility,  seat  of      68 
Site  for  sex  gland  implantation      233 
Spermatorrhea      170 

—  as  a  complication  of  nervous  disease       177,  183,  184 

—  definition  of       171 

—  etiology  of      173-179 

—  hypochondriasis  in       185 

—  neglect  of,  by  physicians       170 

—  pseudo      177 

—  symptomatic       183 

—  symptoms  of       179 

—  treatment  of       186 

—  varieties  of       177 
Spermatozoon,  kinetic  energy  of      215 

—  vitality  of,  in  relation  to  sterility      110 
Spermuria       182 

Spitzka,  sexual  perversion,  theory  of      39 
Sprague,  peculiar  case  of      45 
Sterility — 

—  general  considerations  of      97 

—  in  the  female      159 

—  etiology  of       159 

—  treatment  of       167 

—  in  the  male       104 

—  etiology  of       105 

—  treatment  of       114 
Sterilization      92 

—  treatment  of  spermatorrhea  by      51 

Stich,  transplantation  of  ovary   (foot  note)       222 

Stricture  of  the  urethra,  sterility  from       109 

St.  Hilliare,  theory  of  hermaphroditism       15 

Suggestion  therap3%  as  a  remedy  for  sexual   irregularities      90 

Syphilis — 

—  as  a  cause  of  impotence  and  sterility      137 

—  of   brain,   simulating   dementia   prgecox,   case  of       254 

Tabes,    spermatorrhea   in       183 

Tardieu,  sexual  perversion,  case  of       44 

Thiersch,  theory  of  virethal  deformities      20 

Thompson,  sexual  indulgence,  as  a  cause  of  prostatitis       174 

—  sexual  phenomena  in  prostatitis       183 
Topinard,  sexual   symptoms  of  tabes       183 

—  2,2,2  — 


INDEX 

Tuffier  and  Martin,  method  of  ovarian   implantation       235 
Tumors  of  brain,  relation  of,  to  satyriasis       54 
Tunica    vaginalis,    advantages     of     sex     gland     implantation    in 
vicinity  of       233 

Uncleanliness,  relation  to  masturbation      64 

Undue  familiarity  in  marital  relation       164 

Urquhart,  heredity  in  sexual  perversion,  case  of       47 

Unphysiologic  coitus       84 

Urethra,  congenital  deformities  of       19 

Urethral   catarrh,   relation   of,   to   pseudo-spermatorrhea       182 

Urethral  defects,  etiology  of       19,  20 

—  Thiersh's  theory  of       20 
Urnings       11 

Vasa  deferentia,  anastomosis  of      94 
Vasectomy      92 

—  indications  for      93 

—  technic  of      94 

Vecki,  impotence  from  disturbance  of  olfaction  137 
Vena  dorsalis  penis,  resection  of,  for  impotence  149 
Vesiculae  seminales,  hyperesthesia  of,  in  spermatorrhea       174 

Waldstein  and  Ekler,  experiments  on  female  blood  after  coitus 

(foot  note)       220 
Wassermann  test,   in   sex  gland  implantation      241 
Weissman,  theory  of  germinal  selection       18 
Wharton,  sexual  perversion,  case  of      46 
Wilde,  Oscar,  case  of       49 

X-raj- — 

—  as  a  cause  of  impotence  and  sterility       138 

—  efifect  of,  on  function  of  testis       138 

—  on   graafian   follicles      219 

Young   females,   predilection  of    elderly   men    for      55 


—  Z22>  — 


IMPOTENCE  AND  STERILITY 

■with 

Aberrations  of  the  Sexual  Function 

and 

SEX-GLAND   IMPLANTATION 

by 

G.  FRANK  LYDSTON,  M.  D.,  D.  C.  L. 


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